TORONTO 5. CANADA
SCHOOL OF NURSING
THIS BOOK IS A
DONATION BY
Mrs. Ruth Mattice
Oshawa
April, 1961
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LECTURES ON GENERAL
NURSING
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LECTURES
ON
GENERAL NURSINa
DELIVEBED TO
THE PBOBATIONEBS OF THE LONDON HOSPITAL
TRAINING SCHOOL FOB NUBSES
BY
EVA C. E. LtJCKES
MATRON TO THE LOSDOS HOSPITAL
LONDON
KEGAN PAUL, TRENCH & CO., 1, PATERNOSTER SQUARE
1884
6 3
(The rights of translation and of reproduction are reserved.)
PREFACE.
During a portion of my training as a nurse I was privileged
to attend the lectures to nurses given for several years by
Dr. Allchin at Westminster Hospital. I have frequently
been glad that I was fortunate enough to have the nursing
question at the time Avhen my attention was fii'st turned to
the subject, placed before me from his point of view. I
believe this fact to have been of much service to me, and I
hope by this time to many others, for whose training I have
been, in a measure, responsible.
I am also much indebted to Dr. Allchin for his kind
assistance in preparing the plan of these lectures when I
delivered them for the first time to the probationers of the
London Hospital three or four years ago. It will be obvious
to all that, in adopting to a large extent the classification laid
down by Dr. Allchin, I have not attempted to follow it out on
the technical lines indicated and ably carried out by him in
his own lectures. But, partly from having learnt to regai'd
the subject originally from his point of view, and partly from
having failed to find elsewhere any other system which
VI PREFACE.
appeared to me equally clear and comprehensive, I have fi'om
the first utilized his classification as a means of conveying in
the most systematic method such information on the general
details of nursing as appears essential for the teaching of
nurses. At the same time I must not conceal from the
public that for the bulk of the material in these lectures I
alone am responsible. I am glad, however, to have this
opportunity of gratefully acknowledging my personal obliga-
tion to Dr. Allchin. In compiling these lectures I read many
works connected with the subject, with the view of getting
together as much useful information as possible for the
benefit of those I had to teach. I have been much helped by
several of these works, and in making use of the valuable
suggestions I have found I have endeavoured, as far as
possible, to acknowledge the source whence they were derived.
So much has already been written on the subject of
nursing, that there is but little scope left for originality, and
my sole object has been to collect as much practical informa-
tion as possible, and place it before those studying the matter
as simply as I could.
It will be remembered that these lectures only form the
first course of the complete set given every year to proba-
tioners training at the London Hospital. I have confined
myself for the most part to minute details, that are usually
considered almost too trivial to mention, and I believe it is this
fact which chiefly explains the kind appreciation they have
met with from the probationers, and the frequent requests for
PKEFACE. VU
their publication. I hiave felt the more at liberty thus to
limit my instructions, from the knowledge that everything I
have failed to teach -will be more fully and ably set before
the probationera in the courses of lectures which regularly
follow mine. Mr. Treves' lectures on Elementary Anatomy
and Surgical ' Nursing are complete in themselves, and the
same applies to the lectures on Elementary Physiology and
Medical Nursing so kindly given by Dr. Sansom. The repeti-
tion involved in listening to different lectures much on the
same subject can scarcely fail to make the information given
more familiar to the hearers, and I heartily share in the
gratitude felt by the whole nursing staff for the unwearied
kindness and patience with which these gentlemen have
been careful to make the theoretical education of the proba-
tioners of the London Hospital thorough, comprehensive, and
complete.
I take this opportunity of mentioning this fact, because I
should be sorry for any one reading these lectures to be under
the impression that they indicate the limit of the instruction
given in this training school for nurses. At the same time,
if these lectures contain useful information, I can but hope
that their publication will extend the possibilities of such
usefulness as they may possess. In the first place, I am
hopeful that in this form they may be of service to past,
present, and future nurses of the London Hospital ; and, in
the second place, that other hospital and private nurses may
derive some benefit from them.
VIU PKEFACE,
I am anxious to express my very cordial thanks to all
those who have at any time helped me, directly or indirectly,
with any hints or suggestions in connection with nursing. I
could not have expressed such definite views as I have
occasionally ventured to do had they not been derived from
the practical knowledge of many accomplished nurses as well
as from my own personal experience.
EVA C. E. LtJCKES,
Matron to the London Hospital.
March 3rd, 1884.
^*.>,
CONTENTS.
LECTURE I.
PAGK
The distinction between the work of doctors and nurses — The rela-
tion they bear to each other in the work — What trained nursing
is — The personal qualifications desirable for a nurse ... 1
LECTURE II.
The nurse's part as an active agent in carrying out " rest" when
employed as a means of treatment, including bed-making, the
washing, and various minor details connected with the nursing
of helpless patients ... ... ... ... ... 24
LECTURE III.
The principles of bandaging — The padding of splints — General
preparation and application of surgical dressings ... ... 46
LECTURE IV.
The employment of cold and heat as remedial agents, and the
manner in which they act — Local and general applications of
cold, including ice, evaporating lotions — General applications
of dry and moist heat, etc. ... ... ... ... G9
CONTENTS.
LECTURE V.
I' AGE
Local applications of dry and moist heat — Hot bags, poultices,
fomentations, etc. ... ... ... ... ... 88
LECTURE VI.
Counter.irritation, dry and wet cupping, leeches, blisters — Pre-
vention and nursing of bed-sores — Undressing of accident cases 101
LECTURE VIL
The nurse's duties in contfection with the various methods of
administering drugs ... ... ... ... ... 118
LECTURE VIII.
System of observation of the sick to be cultivated by trained nurses
— What details are specially to be noticed — System and manner
of reporting to the doctor ... ... ... ... 144
LECTURE IX.
Operations — Nursing of special operation cases ... ... 160
LECTURE X.
On the nursing and management of sick children ... ... 174
LECTURE XI.
On the nursing of infectious diseases — The nurse's duties in pre-
venting the spread of infection ... ... ... ... 192
LECTURE XII.
Ventilation, warmth, and light of wards or sick rooms — General
summary of nurse's work, and the standard of excellence
desirable to be attained ... ... ... ... 213
The following is a list of works on nursing that may be consulted
with advantage : —
" A Handbook of Nursing." C. Wood. Cassell, Patter, Galpin, & Co.
" Notes on Nursing." F. Nightingale. Harrison, Pall Mall.
" Handbook for Hospital Sisters." F. Lees. Dalby, Isbister, & Co.
" Handbook for Hospital Nurses." ilorrell. Rivington.
" Handbook for Nurses of the Sick." Veitch.
" Handbook of Nursing," published by Lippincott & Co.
" Notes on the Care of the Sick." Brinckman. Palmer.
" Medical Nursing." Dr. Anderson. Maclohose & Sons, Glasgow.
" Manual of Nursings" CuUingworth. .1. & A. C. Churchill.
LECTUEES ON NUESING.
LECTURE I.
You all know tbat the cure and care of the sick and injured
depend mainly upon doctors and nurses.
The science of medicine and the art of_nursing materially
assist each other in their ultimate objects; i.e., of the cure
"where that is possible, and, failing that, of the alleviation of
suffering.
I want you fully to recognize the wide distinction, both in
kind and in degree, between the knowledge necessary for a
doctor and the knowledge necessary for a nurse, that you
may have a clear and definite idea in your minds of what a
" trained nurse " should know and be, and that you may not
waste time and energy in endeavouring to acquire the sort of
information that will not be of real service to you in your own
distinct work.
When you reflect for a moment what a complicated
machine the human body is, and what a vast amount there is
to be learned respecting it, you will not find it difficult to
believe that years of study are not sufficient to attain a com-
plete knowledge of it. There is the study of anatomy, which
teaches us what the body is ; i.e., its general structure, size,
weight, and so on. The relationship and position of each
c
2 LECTURES ON NURSING. tLEcr. I.
separate organ, how and of what material each part is made ;
— this alone, with the daily advancing discoveries of science,
is an inexhaustible source of study. The same may be said
of physiology, which is the science that teaches us what the
body does ; i.e., how the heart beats, for instance, and how the
different organs work. Then the chemical composition of the
body — the various elements of which it is composed, and how
the various tissues are affected by different things. This forms
the third science which is essential to the understanding of
the human body — first, in its healthy condition, and next
under the varied morbid conditions of disease. But when all
this is known, it only becomes the groundwork upon which
the doctor builds his subsequent studies into the nature of
disease, how to find it out, how to prevent it, and how to
cure it.
It is evident that the most studious nurses can only gain
a superficial knowledge of all these subjects, and fortunately
it is not necessary that they should be thoroughly acquainted
with them. But it is essential that you should know those
points in each science that will materially assist you in the
cultivation and understanding of the art of nursing itself.
It is very desirable that you should have a clear idea of
what a doctor is, and what relation you, as nurses, bear to him.
The doctor, when called to a sick person, first turns his
attention to finding out what is the matter. This may be
very obvious, such as a broken leg, an epileptic fit, or an
attack of measles, or it may require a good deal of examining
and questioning on his part. When once he has made a
diagnosis, as it is called, or ascertained in what way the
patient is affected, he proceeds to determine a plan for the
treatment of the case, and, if need be, to prevent any spread
of disease to those about. Up to this point, you as nurses
have no place. In the subsequent conduct of the case, it
will be your part to efficiently carry out the doctor's orders,
Lect. I.] LECTURES ON NURSING. 3
and to intelligently and carefully obsei've, for the purpose
of repoi'ting with absolute accuracy, what occurs in the
doctor's absence. It is by educating your perceptive faculties
in thia direction that you may become of such valuable
assistance in aiding the cure and alleviation of the sick
But important, and very impoi-tant, as it is that you
should be strictly accurate in such points, it is, after all,
as agents in administering a system of relief to the patient
that you find your place. In the treatment of the case you
have your work.
A plan, based upon scientific principles, is laid down by
the doctor to himself, and he entrusts much of the carrying
out of that plan to you. Hence, at the outset, you see that
your work is of no mean order, and that you are placed
in a responsible position, requiring intelligence and skill ; that,
in fact, you are the practisers of an art, now acknowledged
to be such, and which depends for much of its advancement
upon you. No doctor can refuse to learn of some matters
from a nurse, for he is conscious of her greater familiarity
with, and even of her greater aptitude in, many details ; but
he will most properly resent any interference on her part
with those subjects which are within his own sphere. Hence
it comes that you have to consider the methods of administer-
ing relief. How to make poultices, and how to put them on ;
not lohy and loJien, that rests with the doctor. How best a
patient may be made comfortable in bed, and how that bed
may be made ; not why he should go to bed, nor how long he
should remain' there.
Your work as sisters and nurses is neither to rival nor
interfere with that of doctors ; but in every sense to lielp
them. Is not nursing so distinctly a woman's work, chiefly
because it is helping work, if it is rightly done ? This has
been, or should be, the characteristic of woman's work from
the Creation ; so it is by no means taking a lower standard for
4 ■ LECTUBES ON KURSING. [Lect. I.
ourselves to acknowledge this, or rather to aim that it should
Tbe so, and I think in working we cannot do better than keep
this idea in our minds.
Scrupulously avoid anything which approaches to amateur
doctoring, not only for your own sake, but for the sake of the
whole nursing profession. It prejudices all who come in
contact with it against the education of nurses, and is held in
as much contempt by all really accomplished nurses as any
other sort of quackery is by duly qualified practitioners.
You must not think, because I am anxious to put you on
your guard against those errors which bring so much dis-
credit upon trained nurses, that I am inclined to underrate
the importance of your work. On the contrary, I am desirous
for you to realize that it ultimately depends not upon the
public, but upon yourselves, whether you will let yourselves
be universally considered efficient helps, and be valued and
respected accordingly, or whether you will prove yourselves
unworthy and incompetent to fill the satisfactory position
which is now open to you.
I want you to think very seriously of the work you have
taken up. It is not easy nor insignificant. If you arc
tempted to fancy so, think of the power which rests in your
hands. How completely all the doctor's efforts for his patients
may be frustrated by careless carrying out, or neglect of his
orders, and how terrible the consequences may be ! Life may
be literally lost, or suffering cruelly increased by ignorant oi-
inefficient nursing. So very much depends upon you that you
can scarcely exaggerate the importance of making yourselves
in every way fit for the trust which is reposed in you. If, on
the other hand, you measure your work by its difficulties, by
the patient courage which it demands from you, by the real
strength of character which it takes to go on quietly doing
the sometimes disagreeable and often wearisome duties which
fall to your share day after day, or night after night, as the
Lect. L] lectures on NURSING. 0
case may be, you will not be inclined to say that nursing' is
work that "anybody can do."
We hear of people being "born nurses," as though some
favoured mortals came into the world with an instinctive
knowledge of the subject ; but experience shows us that this
is not exactly the case. Doubtless some have much greater
natural gifts for nursing than others ; but this, like other
arts, such as music or painting, must be carefully cultivated,
studied, and practised, before satisfactory results can be
produced, and the real talent, which some are fortunate
enough to possess, is duly developed.
I would have you set a very high standard before you, and
earnestly resolve that you will not rest satisfied with attaining
anything short of the very best. Your object must be to do
everything connected with your patients in such a manner as
never to give them the least unnecessary pain or discomfort.
It is worth while taking a great deal of trouble over quite
a small detail — and to take trouble is not necessarily to take
time, for to be gentle as well as quick is a habit gained by
proper training — if by so doing you can cause less suffering ;
and the knowledge that you are able to do this, is one of the
greatest pleasures you will derive from becoming skilful.
Unless you are prepared to be very patient and pains-
taking over all the innumerable "little things," your work
will never be thoroughly " trustworthy," and consequently
no credit to yourselves or others. You must endeavour to
learn and to do as much as you possibly can, and not rest
C07itented with " as little."
You have chosen a profession in which there is simply no
limit to the good you can do. Strive to see what your
opportunities are, and then take care not to waste them. You
are working in a public institution, where all you do and say,
and all that you yourselves are, has a wider influence for good
or evil than it would do in the narrower home circle, and Ave
6 LECTURES ON NURSING. [Lect. I.
cannot alter this fact "by shutting oui^ eyes to it. As nursing
is so pre-eminently the woman's profession, what sort of
women must you not resolve to be ?
If only all of you could understand, when yoa enter a
hospital, that henceforth in a double sense you must " walk
worthy of the vocation wherewith you are called," it would
be very helpful to you, and it could scarcely fail to have a
beneficial influence on your work. Let it make you the more
careful, too, to remember that each one amongst you, indi-
vidually, is more or less responsible for the credit of the whole
institution. If any one of you behaves in such a way as to
disgrace the uniform you wear, all the others suffer for it in
the general estimation.
Each one of you who wins our certificate of training will
have it in your power to make us proud of your connection
with us in the future, or very sadly the reverse. You know
how rejoiced men are when a member of their hospital or
college has won distinction of any kind, and how they feel
that his credit reflects itself to an extent upon them. Let it
be the same with you. Many of you can be first-rate. It
rests with you to make up your minds that you will be ; and
having done so, how are you to set to work ?
I would have you consider a little some practical details
concerning this inuch-talked-of hospital training, and such
reflection will probably help yoii to banish a few of those pre-
conceived notions concerning it which are apt to stand in the
way of beginners. If you think of the subject as a whole,
I believe you will share the opinion of those who have given
much careful thought to the matter, and freely admit that it
would be difficult to conceive any system more calculated to
l^roduce good results than the one adopted here. The fact
that you have perfectly regular and uninterrupted courses of
lectures on nursing, and that each one of you is enabled to
attend them all, is not a small advantage. Then the division
Lect, I,] LECTURES ON NURSING. 7
of these lectures into three sets, not only gives each branch
of your -work due consideration, but of necessity, on a subject
of limited extent like nursing, it involves the repetition by each
lecturer of a great deal that has been said before, combined
with the new matter set before you, and this repetition of
essential details can scarcely fail to impress them upon your
minds. In addition to these lectures you have an increasingly
good library on the subject that you are here to study, and
every facility is afforded for you to avail yourselves of it, so
that even without your practical work in the wards your
theoretical knowledge of nursing should be excellent. The
combination of this with the advantage of actual personal
experience in the wards, has not only the merit of being
invaluable in itself, but adds at the same time a double
interest to the theory of your art, and leaves little else to be
pro\'ided for the efficiency of your training. The success of
these means must rest in a great measure upon your applica-
tion of them individually, and in cases where they fail to
produce a good result there must be either the want of
capacity to excel or a grave error in the method with which
you have set to work.
It seems to me that some of you expect to be taught
exactly as though you were children. In teaching a child we
should frequently pause to ascertain how much had been
understood ; we should keep more or less to one point until
it was learnt perfectly, and if no pains were taken we might
say that nothing else should be done until the lesson was
accomplished. Obviously that is not a system by which
hospital nursing could be taught, any more than it is a
subject which childi-en could study ; and it is desirable that
you should each have a clear idea in your minds of the way
in which you are to acquire proficiency. Children frequently
have no desire to learn. Presumably not one of you would
be hei'e unless you had made up your mind, for some reason
8 LECTURES ON NURSING. [Leot. I.
or other, that you wished to be trained. If I may apply a
very homely simile to the matter, perhaps I may make my
meaning clear to you. If a dish of knowledge is placed
before you, you, being grown-up women, and wishing for
this knowledge, must heljp yourselves to it, or go away without
any. If you were little children Ave should feel it a duty to
go round with a spoon and feed you, and in that case we
should provide food for that process. As it is, we cannot
force you to swallow it ; such a proceeding would neither be
polite nor practicable. It is not possible for us to do more
than prepare this knowledge for your use in as palatable
a form as we are able, and entreat each one of you to partake
of as much as you possibly can. I say this to you that you
may recognize the value of your opportunities at the begin-
ning, in order to avail yourselves of them. We can do
everything short of making you learn ; that you must do for
yourselves. If you do not clearly understand what you are
told, make a point of asking questions about it until you do.
Perhaps it may not be convenient to do so immediately ; but
then keep a rough note-book, and make memoranda of the
things you want to know, until a good opportunity offer? of
getting them explained. Nothing would give me greater
pleasure than to attempt to solve some of your individual
difficulties for you; but before I can do this, you your-
selves must take the trouble to tell me what th^y are. Ask
the sisters or your fellow- workers, or any op^ you like, but
find out somehow, and persevere until yoii^ know. Do not
rest satisfied with having asked, remember, until you are
confident that you understand the ma;'tter so well that you
could explain it to another. It is not in the least discredit-
able to you to display ignorance on the most commonplace
detail of nursing now. You are not expected to know any-
thing about it to begin with, even if it happens that you do.
If you knew all about hospital nursing it is not to be supposed
Lect. I.] LECTURES ON NUBSING. 9
that you would devote at least two years of your life, as the
majority of you intend, to the study of it ; so do not let any
fear of being laughed at for not knowing keep you from
asking questions, and do not be discouraged from asking
again in other directions if your attempts to find out what
you wish to know have been unsuccessful. It is no disgrace
to be ignorant iiow, but you will not be able to say the same
at the end of your training, if you have failed to acquire what
it was your duty to learn. If when it is your turn to teach —
and remember every certificated nuxse becomes an authority
on the subject, at least to those who know nothing of it — if
when you are asked the simple questions that you have a
right to be asking yourselves now, you cannot give informa-
tion to others because you have been too careless, too apathetic,
or too silly to ask for it, I think then you might well be
ashamed to confess that "you do not know."
If I have made myself clear to you, I can only beg you all
to make up your minds to set about learning in the right
way, and realize to what an important extent the quality of
your training depends upon yourselves. We will not fail to
do our part, and I want you to begin by doing your very best,
applying your brightest energies to the task you have under-
taken, with plenty of hope and courage to start with, and
a good supply of steady perseverance to carry you through.
It is your first object to do your own duty faithfully and
well, but do not forget that you must also help your fellow-
workers to the utmost of your power. I have often heard
both sisters and nurses exclaim, "I never shall forget my
first day in a hospital ! " Yet I am sometimes tempted to
think they must forget very completely or be sadly deficient
in sympathy, when they can fail to give a thoroughly cordial,
friendly greeting to every new beginner with whom they come
in contact. As I am addressing probationers chiefly, the re-
collection of your first appearance must still be fresh in your
10 LECTURES ON NURSING. [Lect. I.
minds, and I hope for the sake of others that you will keep it
so to some purpose. If you have been fortunate enough to
be received in a kindly spirit by those with whom your
practical work commenced, show a grateful remembrance of
it by extending the right hand of fellowship immediately to
every new-comer. Should they prove unworthy, it is time
enough to withdraw it again, but give them some encourage-
ment to start with. On the other hand, if you have little to
be grateful for in this way, let the thought of the discomfort
you experienced make you doubly eager to save others from
it. I lay a good deal of stress on this commonplace incident,
because it is one of those in which you can do so much to
help each other, and in which I can do scarcely anything to
help you. It may be that my sympathy with those going
through the little ordeal of a first beginning is the more
active because it occasionally happens that I know something
of such circumstances as may have led them to take to this
work. But be this as it may, however kindly disposed I may
feel towards any stranger, you know that week after week
may go by without much opportunity of my giving any
evidence of it beyond the ordinary formal greeting. Whereas
you are workers together, and may be of much service to
each other. Another reason why I am careful to speak of
this is that many of you may fail to overcome the shy
awkwardness which some experience in speaking to a sti^anger,
because they do not realize how thoroughly the effort is
w^orth while. It is one of the little things apt to be left
undone by the most good-natured simply from want of
thought. Possibly there is a little tendency in a continuance
of hospital life to produce the spirit which inquires, " Am I
my brother's keeper ? " Guard against it, please.
Now, in order to become the sort of nurse that I have
described to you there are various essential qualifications in
which you can do much towards ti'aining yourselves, and
Lect. I.] LECTURES ON NURSING. 11
without which nothing we can do for you will ever make you
worthy of the name of a " trained nurse."
Truthfulness, obedience, and punctuality are simply in-
dispensable qualities. Do guard yourselves against the many
temptations which a nurse finds not to be strictly accurate.
Forgetfnlness is a fault for which a nurse should never _
excuse herself, but do own to that steadily rather than give
a false impression. No one will lose confidence in you if you
own your fault ; they will see that you care more for what is
right and for your patients than you do for yourself. It is
degrading to your own character to be untrue, and it may
be hannful in its result to your patients also. You will
have to learn a great deal before it will be possible for you
to give a thoroughly accurate report of your case, because to
do this you will need to know more fully how and what to
observe ; but the very newest and most inexperienced among
you can realize the importance of being extremely exact in
your statements.
Prompt, intelligent, and careful obedience is perhaps of
all others the distinguishing quality of a perfect nurse. It is
the one which inspires the doctor with more trust in her than
anything else will do, and which shows that she really undei'-
stands her work. No one who has not acquired the habit of
quiet obedience to orders, whether she happens to approve
of them or not, has any right to be considered a " tmined
nurse." Implicit obedience is the clear duty of a probationer,
and you must not add to the difficulties of those whose duty it
is to rule by questioning what they say. The responsibility
does not rest with you. There may be many excuses for
ignorance on the part of the probationer, but be sure there
can be none for disobedience.
And, while I am speaking on this subject, let me remind
you of the duty you have to perform in the way of being
very loyal to those under whom you are placed.
12 LECTURES ON NURSING. [Lect. I.
^ I know it is pleasant when you are able to love and admire
those for whom and with whom you are working. It makes
your work much brighter and easier, and I am always glad
when you are fortunate enough to be able to do this. But
when you have not the help of personal affection ; when you
feel that perhaps they are not treating you quite fairly, or
are not setting you a good example in this respect by loyalty
towards those in authority over them; — I want you to under-
stand that 'no failure of duty on their part alter-s your duty
towards them. You are not responsible for their faults, but
you are for your own actions. It is a fault to speak against
the head of a ward to those who have to work under her ;
so, whether you may happen to be right or wrong in your
opinion, if you cannot sincerely praise, try and be silent.
You can learn something from every one with whom you
come in contact. It may be an example of what you would
do well to copy, or it may be what you must take pains to
avoid. In any case, it is not your part to criticize, though
your judgment may be correct. Remember, you cannot quite
judge of their difficulties until you have been in their place.
The regularity of hospital life is, or should be, helpful to
you in gaining the habit of punctuality ; and you must not
be satisfied with yourselves, any more than I shall ever be
satisfied with you, until you have become perfect in this
respect. Why should you not be so ? It only means taking
a little trouble.
An unpunctual nui'se has lost her patient before now by
neglecting to administer the prescribed medicine or stimulants
at tlie right time. It seems almost ridiculous that I should
x'emind you that when food, medicine, applications, etc., are
ordered at any particular time, it means that the patient is to
have them at that hour, not that you are to begin to get them
ready. But I have seen and known so many nurses fall into
this error that I think it is necessary for me to point it out to
Lect. I.] LECTURES ON NURSING. 13
you. Sometimes the consequences of these delays are serious,
sometimes they are not important to the patient ; but they are
always important as indicating a slovenly habit in yourselves.
If a poultice is ordered at a certain hour, try and have it
ready when the clock strikes ; do not wait for it to strike
before you begin to think about making the poultice, and
then rest under the delusion that you are punctual !
Do you see how much is required to make your work
really trustworthy? I need not linger to speak of other
nursing qualities, such as memory, forethought, cleanliness,
calmness, cheerfulness, neatness. You know, without my
telling you, how valuable they are, and what a difEerence all
these things make.
The 'cultivation of what may be termed good hospital
manners is another point to which I must call your attention.
Not that I wish to make this of equal importance with the
other things of which we have just been speaking, but
because they must not be overlooked ; and I think a few
hints on the subject will be of service to you.
You can see for yourselves that manners which would be
quite suitable at an entertainment, for instance, would not
be adapted to a church, or behaviour that would be quite
pleasant and comfortable in your own homes would not be
at all proper in the streets. Hospitals ai*e public buildings,
and you must endeavour to remember this, and conduct
yourselves accordingly. "Manners are not idle;" they in-
dicate a great deal. Besides, they are much within our own-
control. It seems more natural to some than to others to
have what we call " good manners ; " but they can be acquired
by every one with so Uttle cai-e and trouble, that there is no
excuse for neglecting them.
A kindly, pleasant manner to your patients is of gi-eab
importance. It is such a good quality for a nurse if it can
truly be said of her that she never renders the most disagree*
14 LEOTURES ON NURSING. [Leot. I.
able service ungiucioixsly ; and you will add immensely to the
gratitude, as well as to tlie comfort, of your patients if you
try and act up to this. It will be well for yourselves, and
for those with whom you come in contact, if you can always
recollect that " if a thing' has to be done at all, do it
pleasantly."
Is it not curious that hospital nurses, beyond other people,
should often completely forget the injunction, " Be pitiful,
be courteous " ? It ia especially when your patients are weak
and helpless and irritable that you' need to be gentle and
considerate towards them ; they are so completely in your
power, and they may so easily be made to suffer more than
they need do, by your having a sharp way of speaking, a
rough touch, or a grumbling manner of attending to them.
You are giving up a part of your life to wait upon them ;
then surely it is worth while to do it cheerfully.
If you fail in these little ways, it does pi'ove that you are
lacking in true womanly pity and tenderness, and that you
are so far unfitted for your post. The best guide for you to
ascertain for yourselves whether you are failing or succeeding
in this particular, is simply to judge, not whether you are
more or less gentle than some of your fellow-workers, but
whether you would like to have such offices as you may have
to perform for your patients rendered in the same manner
that you are adopting towards them. Remember that you
can be perfectly kind to your patients, and yet never allow
them to speak to you too familiarly or he on too free and
easy terms with you.
Loud voices, and noisy, squeaking boots are thoroughly
unnurselike, and often so distressing to patients, that I should
scai'cely have thought it necessary to speak of them, if I did
not know, from daily experience, how slow some of you are
to discover the importance of these very obvious defects. I
am sure it cannot hav« occuired to some, who appear to think
Lect. I.] LECTURES ON NURSING. 15
it hard or unreasonable that they should be expected to
conform to the requirements of hospital life in such details,
what selfishness they display in allowing patients (who are
not exactly in a position to complain) to suffer discomfort — .
to use no stronger word — rather than incur a certain amount
of inconvenience themselves ! I venture to think that women
who are not above such small considerations of personal
vanity are scarcely worthy to take up the work upon which
they have entered. Much character is displayed in little
actions of this kind, and selfishness is pi'e- eminently a defect
which disqualifies a woman for the nursing profession. It is
an evidence of such thoughtlessness that I do not wonder
doctors speak as they do of those who indulge in them. You
can easily understand for yourselves how objectionable these
disturbances ai-e; and I wonder occasionally, when I see a
nurse rushing and clattering about, when perhaps the doctors
are using their stethoscopes, how it is they do not complain
of it even more ; but they can scarcely fail to notice the want
of perception which any one doing such a thing displays.
As far as your manner to the matron is concerned, I need
not say much, for I could not wish for anything pleasanter
than the consideration and the bright, ready coui-tesy I receive
from you all. But one point I will mention for your own
satisfaction, because the sisters have told me that you are
sometimes puzzled about it. When I am in the wards, unless
the sister is free to attend to me, I like whoever is doing stalf-
nurse's duty, or, if she is in attendance on the medical
officers, any probationer that may be on duty there, to go
round with me. I like this for two reasons. One is that it
is convenient to have some one close at hand to answer any
question I may want to ask ; but the other, and perhaps the
stronger, reason is that this is one of the few opportunities
1 have of speaking to you individually. We live such busy
lives that it is comparatively seldom that we come into pertsonal
16 LECTUEES ON NUHSING. [Lect. L
contact, and it is always a pleasure to me to meet those in whose
welfare I feel so much interest. I am naturally reluctant to
miss such opportunities as occur. I equally like you to
accompany visitors when they are being taken round the
ward, whether I am with them or any of the other hospital
officials. Sometimes it may happen that you are helpful in
answering questions. At any rate, it is always pleasant and
desirable to see you at hand, so do not be afraid that you are
in the way. Never remain seated when visitors are passing
through your ward.
I must also remind you of the courtesy that is due from
every member of the nursing stafE to strangers who enter the
wards unattended. It is an extremely awkward feeling to
go into a ward, whatever your mission there may be, and find
yourself completely ignored. If any of you have ever tried
the experiment yourselves by going, as a stray visitor, to any
other hospital, and should happen to have been greeted with
the indifference of which I speak, I am confident that you
will retain such a melancholy recollection of the event that
you will never leave others to experience a similar fate. It
is the distinct duty of the nurse in charge of the ward, or, if
she is engaged at the moment, for any probationer present,
to go up to any stranger who is hesitating where to go or
what to do next, with the simple question, " Is there anything
I can do for you ? " The visitor may be of no special con-
sequence, but your manners are always of importance ; and
it would distress me personally, and be a reflection upon all
our nursing staff, if any member of it is found wanting in
that ready courtesy and kindness which is admirable under
all circumstances, and almost a necessity for those who are
in any way connected with the public life of a hospital. I
have heard that there are persons who, by some extraordinary
perversion of ideas, are under the impresssion that it is
derogatoiy to their dignity — or " beneath them," as I believe
Leot. I.] LECTURES ON NURSING. 17
the phrase goes — to pay attention to such little matters as
these, or to show the consideration, if I may venture to use
the term, due from all wearing our hospital uniform to those
who may address them, apart from any question of the social
standing on either side. There are other persons, again — and
I believe these are more numerous — who rather pride them-
selves on a certain abrupt curtness of speech, most unpleasant
to those who have to submit to it, but which the speakers
en-oneously think amply atoned for by the explanation that
it is " only my manner ! " If that is the case, the sooner it is
altered the better it will be for all concerned. I refer to
these delusions, though I hope no one here is labouring under
them. It can do us no harm to be duly impressed with the
practical truth conveyed in the poetical statement, that " the
gentler born the maiden, . . . the more bound to be sweet
and serviceable."
Next, with regard to your official manner to the sisters.
Do not sit down, nor remain sitting, when the sister is giving
you orders about the patients or your work. It is not polite,
and does not look well. Of course, it is different if you are
only talking together. The social position of yourselves or
of the sister does not affect the question at all. This is
simply the courtesy due to the sister of the ward from those
working under her. She has too much to do to be constantly
reminding you ; but be particular about these little things
for your own sakes ; it may be that you will want to teach
them to others by-and-by.
Probationers and nurses must not report anything to the
medical officers in the presence of the sister. If there is any
information that should be made known, the probationer
must tell the sister, and it is for her to report it to the
medical officer. Sisters are responsible for all that goes on
in their ward, and it is your duty to help them, by keeping
them promptly and carefully informed of any points con-
C
18 LECTUEES ON NURSING. [Lect. I.
nected with the patients ; but you must avoid taking her
place when she is there. If you are attending to the medical
officer without the sister, then, of course, you must give him
all the necessary information; but it is a very "untrained "
thing for a nurse or probationer to answer or ask questions,
or give reports, when the sister is in attendance.
I am very distinct and definite about these small things,
because, when you are once told, you need not forget them ;
and I am confident that many of you will feel helped by
knowing what is correct in these little matters. It is not
possible to know them by instinct, and it is a disagreeable
experience to find them out by making mistakes. Of course,
you will never think of sitting down or of remaining seated
while you are speaking or being spoken to by any of the
medical staff, whether a senior or junior member of it,
including the dressers and students ; it looks unbusiness-like
and unprofessional. There is, again, no question of social
equality or inequality involved in this ; but if you forget ifc,
those who are capable of judging will know at once that you
are ignorant of ordinary details of hospital routine. You
cannot always help other people's manner to you, but you can
do a great deal towards making it what you wish to have it,
and at any rate you can always help yours to them. It is
not by being frivolous and silly, nor solemn and disagreeable,
that you will hold your own and keep others in their place,
but by a quiet, pleasant, gentle manner to all those with
whom you come in contact.
Think of the harm you do if you give one man cause to
think and speak worse of women than before he entered the
hospital. Give your fellow-workers a chance of respecting
as well as of liking you, and they will not fail to do so.
Remember that it depends upon you, not upon them, whether
they are to leave the hospital declaring that they would not
have their sisters take up such a life for the woi'ld, or
Lect. I] LECTURES ON NURSING. 19
whethei' you will have unobtrusively shown them a little bit
of what is meant by the " beauty of holiness " — as perhaps
only a good woman can do — and have taught them that a
hospital nurse is not the sort of person to be lightly spoken
of or idly trifled with, but one whose interest is centred in
quite other things. You must not leave it for others to help
you to do this. Why should they take the trouble ? But
no one can hinder you, neither will they try to do so, if they
see that you are sincere and in earnest. All affectation is
contemptible and patent to all observers.
If these little details of manner do not strike any new
probationer joining you — and it is quite likely they will not —
take an early opportunity of giving her a quiet hint on the
subject, because it will prevent her looking awkward and
feeling uncomfortable on another occasion.
Be careful not to get into a habit of leaning up against
the tables and chairs, and the patients' beds, under atiy cir*-
cumstances. It always gives an impression of slovenliness,
and, moreover, is quite unnecessary. On the other hand,
take every legitimate opportunity of sitting down and of
resting yonr feet, for you all have a great deal of standing ;
and the more you can save yourselves in this way, the better
it is for you. If you could remember to put your feet up,
instead of only sitting down, when you are off duty, and not
walking, you would be much more refreshed and rested. Most
nurses suffer a great deal with their feet when they first
begin hospital work, and it often makes them feel very tired
when they are quite well otherwise.
It is part of a sensible woman's duty to take proper care
of her own health; because, however good your intentions
may be, you cannot do your work, nor yourself justice, for
long, when you ai-e not well. Plenty of fresh air, and as
much change of scene as possible, are most necessary for
you; and the patients, too, get the benefit of it, Irv yonr
20 LECTUBES ON NURSING. [Lect. I.
being all the brighter on your return to them. Try and
resist the inclination to stay in because you are tired; you
will nearly always be glad afterwards, if you have summoned
up sufficient energy to go out. Hospital work is very absorb-
ing, and it is not at all good for you to get your views of life
narrowed by taking no intei-est in other things, Nurses, of
all people, ought to understand that it is impossible to
keep well and in good working order without regular meals
and fresh air, and both are specially important to those who
are on night duty.
One other little thing I must just remind you of, while
I am speaking about yourselves, and that is the extreme
care you must always remember to take in covering up any
scratch or cut you may have on your hands, if it is ever so
small, while you are in the wards of a hospital. It is not
being fussy to do this, but it simply shows that you have
sufficient common sense not to xnsk poisoning your hand. It
is some little trouble, but nurses must take care of their
hands. If you have forgotten to cover any little place where
the skin has broken, before doing a dressing, immediately
wash it in carbolic, and remedy the omission without further
delay. Nurses ought not to get bad fingers, but they inevit-
ably will do so unless they take every precaution. Carbolic
hardens the hands very much, as most of you know, but you
can keep them soft with glycerine ; and if you are going to
put them into anything very disagreeable, you can fill your
nails with soap. It is much pleasanter for your patients to
be touched by you if you keep your hands and nails in as
nice condition as you can, and it is an important habit for
yourself, I was asked the other day if I could do anything
to assist a nurse who had been obliged to have her right arm
amputated, from having poisoned her finger with a case she
was nursing. I tell you this, not to make you nervous, but
to convince you that you cannot be careless in this respect
Avithout grave risk to yourselves,
Lect, I.] LECTURES ON NUESING. 21
Now, tliei'e are one or two faults and temptations which
people living together in a public institution somewhat readily
fall into, and against which it is well for you to be on your
guard. I dare say many of you will agree with me at once
when I mention the two most prevalent as being gossip and
grumbling.
A hospital is a little world in itself, and I fear the small-
minded notions, spite, and jealousy which too often prevail,
make the conversation of a household of women almost
proverbial in this most undesirable way. If it were possible
to put together the time which is spent in any one building
of this kind in one day, in these two most unprofitable occu-
pations, how many hours would have been thus wasted ?
Gossip ma]i do an immense amount of harm ; it can do no
possible good. The idle stories of each other, or of those
with whom you are working, merely repeated and listened to
for amusement, are often not entirely true ; and, if they do
not fail in this respect, they are not quite kind, and you feel
hurt and annoyed yourselves when you find that others have
been doing the same about yoa. It is not enough " not to
mean any harm ; you must not do any. Each one of you can
do a great deal by making a personal effort not to indulge in
the general tendency to gossip, and by distinctly showing
that you take no interest in such things when others begin
to speak of them.
Grumbling is a little different from gossip, inasmuch as
it does the person who grumbles more harm than anybody
else, though the harm done by no means ends there. When
you have a discontented patient in the wards, who will
not be pleased with anything you do, no matter what
trouble you take, have you not noticed how soon the dis-
satisfied spirit spreads, and how inclined to complain nearly
all the others become ? I need scarcely point out to you that
it is the same in every other community.
22 LECTURES ON NURSING. [Lect. I.
I do not think we have any right to make life harder for
others. I am sure you each find diflficulties to ovei'conie,
without having them increased by any thoroughly depressing
companions. I consider that it is simply due to our best
workei'S that those whose influence has no tendency for good
in this respect should, as far as possible, be excluded from our
number, I am far from saying that you never have anything
to grumble at, but I do emphatically say that, whatever your
grievance may be, grumbling is not the Avay to mend it. Do
not misunderstand me and think that I wish you to put up
with everything you do not like, without mentioning it. I
meaaa, speak of it only to those who have the power to alter
it. That would be complaining to some purpose, and is a
very diffei'ont thing from idly spi-eading a feeling of dis-
content that helps nobody.
Try and remember as much as you can, when you find
things irksome to you, that those in aixthority are sincerely
desirous of doing what is best for all ; and if you cannot
always see this, and do not agree with their view of the
matter, whatever it may be, at least this conviction will
render it less difficult for you to do your part.
If you can keep from gossiping and grumbling, you will
be all the happier yourselves, and a helpful example to your
fellow- workers. I am sure, if you pause to think of it, yoxi
will agi'ee with me, that, "It is better to fight for the good
than to rail at the ill." Success in guarding against or in
conquering these two deplorable failings will be well worth
the constant effort involved in gaining it. Nurses get into
these habits before they are aware of it themselves, just
because " everybody does it ; " but if you will resolve in-
dividually to fight against them, I am confident that we shall
have reason to be satisfied with the result.
I cannot resist quoting to you a remark of Sir Frederick
Leighton's that I came across the other day. "Believe me,"
Lect. I ] LECTURES ON NURSING. 23
he says, " whatever o£ dignity, whatever of strength we have
within us, will dignify and make strong the labours of our
hands ; whatever littleness degrades our spirit, will lessen
them and drag them down. Whatever noble fire is in our
hearts will burn also in our work ; whatever purity is oui-s
will chasten and exalt it ; for as we are, so our work is ; and
what we sow in our lives, that beyond a doubt we shall reap,
for good or for ill, in the strengthening or defacing of what-
ever gifts have fallen to our lot."
Those words appear to me to be full of encouragement.
I shall endeavour in our next lectures to give you some
definite instruction on the different practical details of nursing,
but it seemed essential that we should get a clear idea of the
type of woman that a nurse herself should be, before we
could reasonably begin to talk about the various items of
her work. I earnestly hope that what I have said may be of
service and have weight with you, and that each one of you
will deliberately resolve to attain, as nearly as possible, to
the high standard of nurses and nursing which I have tried
to set before you.
" Greatly begin ; If you have time
But for one line — be that sublime :
Not failure, but low aim is crime."
24 LECTURES ON NURSING. [Lect. IT.
LECTURE II.
In our last lecture we dwelt chiefly upon two important
questions, namely, what trained nursing is, and the personal
qualifications desirable for a nurse. We also considered to
some extent the distinction between the work of doctors and
nurses, and the relation they bear to each other in their work.
We spoke of the similarity in the object of each, as far as the
cure and i-elief of the sick and suffering are concerned, and
of the difference that it is essential for each to observe and
maintain for the efficient attainment of that object,
I need scarcely take up your time with the repetition in
detail of what these distinctions are, I will only briefly
remind you that the diagnosis of the case and the laying
down of 'a scientific plan of treatment is the work of the
doctor. It is as an active agent in carrying out that plan of
treatment that the important work of the nurse lies. The
doctor prescribes ; for the most part it is left to you to carry
out that prescription, and it is obvious that the welfare of
the patient must depend upon the efficiency and mutual help
of doctor and nurse. Any misapprehension of the relation-
ship you bear to each other, any aggressive tendencies on the
part of the nurse, and any want of confidence on the part of
the doctor can but have a disadvantageous effect upon work
which probably you are both desirous of making as perfect
as possible. Doctors can often do so little without nurses
that they are frequently the first to acknowledge that " nearly
Lect. II.] LECTURES ON NURSING. 25
everything depends upon the nursing." This is a familiar
phrase to us in reference to many cases. On the other hand,
it is only right in defei^ence to the far longer, wider, and to
a great extent different range of studies of doctors, that
nurses should help them to carry out whatever means they
may think fit to adopt by prompt and intelligent obedience.
It follows, therefore, that nurses have to turn their atten-
tion to the best means of cariying out whatever details may
be considered under the head of " treatment."
We shall find it helpful to recognize the fact that treat-
ment usually presents itself to us under one or more of three
aspects. First, it may be necessary to provide an antidote
to any poison and to remove all sources of harm ; secondly,
the chief consideration may be to place and to keep the
patient in the most favourable condition for self-cure ; thirdly,
it may be desirable to aid in treatment by drugs which
experience or experiment have shown to be efficacious.*
Sometimes only one method of treatment may be employed,
sometimes two, and frequently all three are brought into
requisition ; but you will find that almost every case of which
you can think will come under one or more of these heads,
and we will, therefore, make them the plan for the first part
of this course of lectures. I shall probably make my meaning
more clear to you by one or two illustrations.
Let us suppose a case of typhoid fever to be due to the
defective drainage or water of the locality in which the
* Amongst much other valuable help I am particularly and entirely
indebted to Dr. AUchin for this system of arranging the subject. I am
aware that I have not extended this classifieation to the fullest possible
limit which it is capable of being extended to, and which those who have
the pi'ivilege of being acquainted with Dr. Allchin's own lectures cannot
fail to appreciate. I am none the less under much obligation to him for
a method which has enabled me to regard the whole nursing question
from a clear point of view, and which I trust may bo of equal service
in teaching others to look at it in a plain, practical light.
26 LECTURES ON NURSING. [Lect. II.
patient is living. Directly the doctor had ascertained this,
he would insist upon the removal of the patient to some
place free from these pernicious influences, and thus, in the
first place, he would cany out the treatment which I have
spoken of under the first heading, and " remove all sources
of harm." But he would not stop there, and consider that all
the treatment necessary for a patient suffering from typhoid
fever was to place him in healthy surroundings, though ho
might reasonably believe all other means useless without this
essential preliminary.
Without entering into all the details of nursing typhoid
fever, most of you know that all solid food is carefully with-
held, that the patient is not allowed to sit up, much less to
stand or walk about. You do not cure typhoid fever by
canying out the usual instructions on these points, but by
taking these precautions you give the disease from which the
patient is suffering, the best chance of running a favourable
course, and thus cany out the treatment spoken of under the
second heading, i.e., " placing the patient in the most favour-
able condition for self-cure."
But the doctor will probably consider it desirable to aid
in ti'Qatment by drugs which experience or experiment have
shown to be efiicacious ; and thus all three methods would be
combined for the successful treatment of one case.
On the other hand, one form of treatment may be sufficient.
Supposing a person to have swallowed a poison, it may bo
possible to administer the direct antidote [to it, as strong
coffee after opium poisoning, or any alkali if an acid poison
has been taken, or if a patient working in a lead-factory
begins to show symptoms of lead-poisoning, he may regain
health and strength by changing his occupation, and so
" remove all sources of harm ; " thus the treatment spoken of
under the first heading would prove sufficient. Then, if a man
has broken his leg, the oiily thing you can do is to put him
Lect. n.] LECTURES ON NURSING. 27
and it in the most favourable position for self-cure, by pro-
curing the necessary rest and position, so that Nature may
perform her own cure without interruption. In this case the
treatment spoken of under the second heading is all that would
be required. Again, there are circumstances in which different
drugs may be considered likely to produce a beneficial effect
upon the system without other remedies being necessary, so
that the treatment spoken of under the third heading Is occa-
sionally employed alone, but this is more often used in com-
bination with one or both of the other forms of treatment.
Now, to repeat '^the statement with which I started, for the
sake of clearness, you will remember that treatment nearly
always presents itself under one or more of three aspects.
First, to provide an antidote to any poison, and to remove
all sources of harm ; secondly, to put the patient under the
most favourable condition for self-cure : thirdly, to aid in
treatment by drugs which experience or experiment have
shown to be efficacious.
In order to make this fact your own, just think of the
various cases in your respective wards, and settle in your own
minds for' your own satisfaction — not necessarily for anybody
else's benefit or information, remembei* — under which of these
headings the treatment of your different patients comes, for
each case could be placed under one or more of them.
Treatment consists in the application of natural agents,
such as rest, heat, cold, light, electricity, etc., adapted to the
special needs of each particular case. Some of you will already
have thought for youi'selves that it is under the second
heading that most of a nui^se's wox-k comes. To place and
to keep the patient in the most favourable condition for self-
cure usually involves more nursing than it appears to do at
first sight.
" Rest " is the natural agent that is constantly employed in
various degrees as a* means of treatment. Rest may be
28 LECTURES ON NURSING. [Lect. II.
*■ complete or comparative, and it Inay be applied to the entire
body, as by absolute rest in bed, or locally, as applied to
different parts of the body by means of splints, bandages, or
other mechanical arrangements. A nurse's duty in carrying
out the treatment of absolute rest in bed includes bed-making
for general and for helpless cases, with the washing and other
attentions needed for such patients as are unable or forbidden
to help themselves. So I propose to deal first with the details
involved in the nursing of a case where the order of complete
rest in bed has been given. The feeding of helpless patients
Ave will speak of when we consider the administration of
food ; but I think we may finish all that needs to be said on
these other points to-night.
First, with regard to bedsteads.
The superiority of iron or bi-ass over every species of
wooden bedsteads is so universally acknowledged that I need
not do more than allude to the fact.
For nursing the sick it is essential that bedsteads should
not be too wide. This is an important consideration, and one
that is frequently overlooked in private nursing. It is im-
possible to move the patient, to change the sheets, or to
attend to a helpless case with any degree of comfort if the
bed is too wide. If there is an idea of affording the patient
relief by changing him from side to side, this plan can be
executed infinitely better by means of two smaller beds that
can be put next each other, for the purpose of lifting the
patient to a fresh place ; and the bed which he has just
vacated can then be moved away without disturbing him,
and the nurse remains able to get at her patient in all
directions in a manner that will contribute greatly to his
comfort. In hospitals, of course, these matters do not rest
with you ; but many of you are training for private nursing,
and it is well to have studied them. For patients who are
able to get in and out of bed, it will fatigue them less if the
Lect. II.] LECTUEBS ON NURSING. 29
bedstead is no higher than a sofa ; but for bedridden cases
rather a high bedstead is less tiring for the nurse, and does
not affect the comfort of the patient in any way. Bedsteads
should never be placed with one side against a wall, except
for the purpose of keeping a delirious patient in bed, for such
an arrangement materially adds to the difficulty of attending
to the patient's wants. Nothing can be cleaner or nicer
than the chain spring bedstead. That, with a hair mattress,
is the best arrangement I know out of many good ones for
all ordinary cases.
Sometimes water beds are ordered, and they are extremely
useful in some cases where pressure must be specially avoided.
When you have to prepare them, remember they must not be
too full, nor quite cold. If you find, it most convenient to
nearly fill them with cold water, add a few jugs of hot water
to conclude with, that there may be no feeling of chill when
the patient is placed on it. The same rule applies to the
filling of water pillows. As a rule, these beds are not very
popular; the patients frequently complain of a feeling of
"sea-sickness."
A spring bed, with a hair mattress and a square water
pillow, is generally the most conducive to comfort if the
choice happens to rest with you ; but if the doctor for whom
you are nursing prefers otherwise, that settles the question
of course. I should say that, as a I'ule, circular water pillows
are preferred in theory, and square water pillows in practice ;
but there, again, circnmstances must decide, and many may
differ from this opinion.
Beds for cases of fracture and others for special cases we
can consider when we come to the nursing of those cases ;
they must be made hard with boards or straw mattresses,
unless the bedsteads are made for special cases, such as our
fracture femur bedsteads here. Flock beds are distressing
to a nurse's, as well as to a patient's, feelings. They are
30 LECTURES ON NURSING. [Lect. II.
so difficult to get into shape, to keep free from lumps, and
to make comfortable. The sole merit they possess for hospital
use is cleanliness. They can be easily replenished ; but I can
only hope that we shall shortly have the satisfaction of seeing
them all i-eplaced by spring bedsteads and hair mattresses.
I do not think that with the shape of iron bedstead now
in use any theory on the subject of ventilation being impeded
by curtains deser-ves sufficient importance to be seriously,
considered, as opposed to the great advantage of the com-
parative privacy they afford, particularly in large wards like
ours, where the publicity is unavoidably extreme. It is a
great comfort to many, not only to be able to put them-
selves partially out of sight, but to be able to shut out
some of the distressing sights which occasionally suiTound
them. Provided curtains are of a washing material, and
changed often enough to ensure cleanliness, and that they are
not arranged in any manner calculated to interfere with
ventilation to any appreciable extent, my own opinion is
stroilgly in favour of them, except, of course, for infectious
cases. I am aware that many differ from my view of this
question, and it is merely a matter of opinion whether the
advantages or disadvantages of allowing curtains to be used
exceed each other. I believe them to be a very desirable
comfort in the charge of a careful nurse, '^but I also admit
that a careless nurse may allow them to become a source of
positive danger, in every case where there is the slightest
possibility of any kind of infection being harboured by them.
It does not rest with you at present to choose the position
of beds for your patients ; but any of you who are training
with a view to employing your knowledge of nursing outside
the walls of a hospital, will find that the choice of all this
mainly depends upon you, and you will often be expected to
understand and explain, not only what is best, but why it
is best.
Lkct. II.] LECTURES ON NURSING. 31
If the bed can be placed so that the patient can see out
of window, so much the better. Let the light fall fully
though crosswaya on the patient, if possible; the doctor
always prefers it. You can shut out light when needful,
but you can never make it come through a blank wall. Some
people haye an idea that it is orthodox to keep a sick room
lather dark. With a few exceptions, it is best to brighten
up your ward or sick room with as much sunshine as you can
possibly get into it. Of course, you would not allow your
patient to lie with the sunshine streaming into his eyes ; but
unobservant nurses are apt to forget that the sun does not
remain in the same position all day, and that if it has been
necessary to draw down the blind for a time, it may soon be
desirable to pull it up again. A dark-green blind is best for
keeping out the light. Sunshine is almost a necessity, and
has a definite and powerful influence for good, physically as
well as morally.
If your patient is well enough to be moved out of bed
while it is made, take care that he is warmly ^n^apped up
with a blanket, and that his bare feet are not left touching
the floor. In some cases a foot- warmer is desirable ; for the
fact that the bed will be made in a very few minutes is no
reason for letting your patient feel cold, or experience any
other avoidable discomfort during the process.
Bed-making should be the first work of the day-nurse and
probationer when they enter the ward in the morning. The
sister must always be asked if the patient may be allowed to
move out of bed while it is made, whenever there is the
slightest doubt in- the matter, for it is all important that some
cases should not be allowed to put their feet to the ground.
It requires two to make the bed properly when the patient is
in it. It is easier to explain the best method of changing
the sheets for a helpless patient, so that yon may thoroughly
understand it, by a practical illustration in the wards ; and
32 LECTURES ON NURSING. [Lect. II.
no doubt some of yoa have been taught it there. This varies
•according to the case.
The great object to be borne in mind is saving the
patient all unnecessary pain and fatigue. Remove all the
top bedclothes, except the sheet or one blanket, which must
be retained as a covering. If the patient can be with safety
turned on his side, oae person should hold him comfortably iu
that position, while the other rolls the under sheet, which is
to be removed, close up to the patient, the whole length of
the bed, and tucks the clean sheet in on that side, placing the
remaining half of it rolled up close to the sheet that is about
to be taken away. The patient should then be gently turned
over on the other side, and held in that position by the person
standing there, while the other promptly draws the sheet off
the bed, pulling out and smoothly tucking in the clean sheet
on that side also. It is of extreme importance to guard
against wrinkles and crumbs in the bed, and it requires no
little care and ingenuity to do this with complete success.
The tiniest rucks in the bedclothes are indescribably uncom-
fortable, and, moreover, are productive of bed sores, when the
skin is in a very sensitive condition. Never shake sheets,
blankets, or, indeed, anything over the patient's bed, but
always away from it.
The clean top sheet must be placed over the patient before
the one which has been retained as a covering has been with-
drawn ; and, remember, there is no occasion to give the
patient all sorts of suffocating sensations, by drawing sheet
and blankets over his head until they are all accumulated,
and you are ready to turn the clothes down at the top. If
the blankets are so long that they need doubling back, this
should be done generally at the bottom of the bed, and not
so that the additional weight and warmth of bedclothes should
lie across the chest. I mention these very small points, because
they are constantly neglected from sheer want of thought.
Lect. II.] LECTURES ON NUESING. 33
IS'ext Ave come to the arraugenient of the pillows, for
which no absolute rule can be given, though every one
knows that a patient's comfort in bed largely depends upon
their skilful adjustment. The principle to keep in view is
that pillows are intended to support the patient in the position
that he wishes or is able to adopt. The lower part of the
back always needs supporting ; the shoulders must have room
to lean back, and the top pillow must be placed in such a
way as to support the head, without either tilting it forward
or obliging it to fall back. The arrangement of pillow^s and
cushions is a very individual matter ; and, "with these general
principles for guidance, only observation and experience can
teach you what is likely to suit each particular case. Nursing
is supposed by some to consist mainly in that graceful task
known as " smoothing the pillow ; " but, though we may
smile at the familiar expression, we must not forget that it is
distinctly refreshing to have the pillows shaken up occasionally,
and the cool side placed next the patient. But one word of
wai'ning in reference to shaking up pillows. Never shake your
pillows 071 the bed. It is wholly unnecessary to shake up
your patient at the same time ; and though in many cases
jerks would not be distui'bing, they are ahvays carefully to
be avoided. I dare say it strikes you that your own common
sense would teach you this ; but notice the first time that you
are tempted to do it, or that you see some one else do it, and
you will find that my warning is not superfluous, and that the
next instance will occur sooner than you anticipate.
Draw-sheets and mackintoshes are managed in exactly
the same way as the under sheet, but of course those can be
changed in less time.
Some cases are best moved in a similar manner to that
which I have just described, from the top to the bottom of
the bed, instead of lengthways ; but these are the exception,
the other is the rule.
34 LECTURES ON NURSING. [Lect. II.
Ill some German hospitals tapes are sewn on to the
mackintoshes and di-aw-sheets, and they are tied to the sides
of the bed. It is a good plan, as it keeps them in place and
free from wrinkles, but it involves a great deal of trouble. I
do not know any English hospital in which it is done. Every
accident bed should be made up with a mackintosh and draw-
sheet. Do not wait for the mattress to be saturated before
discovering that one is necessary. Never put a blanket on
the mattress under the patient, unless specially ordered to do
80 ; " it x'etains damp, and acts like a poultice," * and is, con-
sequently, likely to induce bed sores. When patients are
ordered to lie between blankets, place one ove7' the bottom
sheet, and put the top sheet over the blankets and next the
counterpane or check, so that the bed may look neat.
The top sheet should not be tucked in at the bottom of
the bed, but folded neatly back — over the blankets in those
cases where the bedclothes will have to be turned back in
that way for the surgeon, and back upon itself in those cases
Avhere the blankets can bo tucked in at the bottom of the bed.
It not only looks neater, but leaves the end smooth to put
over the bolster when you use it for the under sheet and put
a clean one on the top later on.
When you are going to make the bed, always place a chair
or something to throw the clothes over, and never under any
circumstances throw them on the floor, where, of coui'se, they
will catch up dust and dirt. I should scarcely have thought
it necessary to tell you this, but I have so frequently seen
them left on the ground.
You must not let the sides or the ends of blankets be
seen dangling below the check or counterpane. It looks
extremely untidy, and, moreover, they get dirty. Turn
* Miss Florence Nightingale's " Notes on Nursing." Amongst others,
the short chapter on " Beds and Bedding " may be studied with ad-
vantage to all interested in this subject.
Lect. II.] LECTURES ON NURSING, 35
back the corners over the pillows crossways if they are
too long.
Hospital bedsteads should never have foot-pieces, and I
hope the day will come when we shall see no more of them.
In surgical wards it is almost impossible to use them, they so
interfere with a convenient position for putting on splints,
dressings, and bandages. They are less objectionable in medical
wards ; but even there it is more difficult to make the beds look
neat with them. In places where linen checks are used, as in
this hospital, they should be tidily pinned round the foot of
the bed to keep them straight and smooth. At hospitals where
thicker counterpanes are used they are folded in such a manner
as to produce the same result, but the lighter material is alto-
gether preferable. It is generally considered that scarlet
blankets form the best sort of covei-lets for the use of the sick.
It is popularly supposed that they help to keep away fleas, but
I will not vouch for the truth of this supposition ! Scarlet
coverlets look bright in a ward, but the glare of the colour
may prove a little trying to some sick people. Notice, if
a patient is restless, whether his bedclothes are too heavy.
Sometimes that makes all the difference to a weak patient,
and it is one of the points for a good nurse to pay attention
to when she finds that a patient is tossing about and uncom-
fortable without knowing why.
Whilst speaking of bedclothes, I may as well i^emind you
that in uncovering a patient for the doctor, you must avoid
exposing him more than is necessary. For instance, when
the feet or legs are to be examined, turn back the bed-
clothes from the foot. In some operation cases, such as
lithotomy, etc., the bed is made in such a way as to facilitate
the removal of the bedclothes in the middle. For examination
of the chest or abdomen the clothes are, of course, turned
down from the top, or it is a good plan to fold back the
check and blankets, and leave the top sheet over the patient
36 LECTURES ON NURSING. [Lkct. II.
as a light covering which the doctor can move at his con-
venience without making the patient uncomfortable. In
obstetric cases it is generally best to fold the clothes back
from the side of the bed.
There is no need to expose the patient in making or
remaking the bed, a process that is so often necessary with
those delirious patients who are possessed with an unceasing
desire to get up. You can always leave a blanket over the
patient while you put on the sheet and other things, and
then slip it out and put it on properly afterwards.
I must not conclude this subject without a word on the
importance of airing the bed and body linen of those under
your care, not only before it is used, when the damp is at any
rate comparatively clean, but when it has been saturated
with moisture from the skin, which is far more unwholesome.
In hospitals you hav^e not generally a very large supply of
body linen for your patients, but if you are obliged to put on
soiled things again, at least you can air them thoroughly, and
make them as dry and wholesome as the circumstances will
permit before replacing them.
You can scarcely realize, unless you have experienced it,
the comfort, and, moreover, the actual benefit a patient will
derive, from having a shirt or blanket which has grown
moist, cold, and offensive with emanations from the skin,
replaced with a dry, warm one.
Of course it does not rest with you, as probationers, at
present to decide when these changes may be made, but keep
the importance of them in your minds, and do not forget that
when you remove a patient's shirt, for the purpose of washing
him, for instance, that it had better be airing by the fire
ready to put on warm and dry, than lying on the bed for you
to replace it in the same condition as it was taken off. Those
of you who are preparing for private nursing should remember
that it is not well to allow any airing of clothes, clean or
Lect. II.] LECTURES ON NURSING. 37
otherwise, in the patient's room. In some hospitals we arc
not quite able to help onrselves in this respect.
In the children's ward we change their bedgowns and
jackets for the night and the day, because it is so much more
wholesome, and whenever you have an opportunity of per-
suading any other patients to do the same, there can be no
doubt it is best for them.
Washing hospital patients is generally rather a formidable
undertaking, and in most cases prompt ablutions are quite
indispensable. Of course injured limbs must be very gently
handled, if they are able to be cleansed at all, and mackintoshes
should be used to prevent the sheets getting damp.
The nurse of a ward should see that the feet of all the
patients are washed at least once a week, and it may in
almost all cases be done without running any risk for the
patient, provided that they are properly dried, and not allowed
to remain cold.
In the daily washing of those patients who are incapable
of washing themselves, only uncover the part you are doing
at one time, and do not keep them with chest and arms
exposed while you are washing the face. Do not begin the
process and then leave them with the water drying in, while
you run ofF to fetch a towel. It is such an uncomfoi'table
thing to be washed instead of being able to wash one's self,
that you must try to make it as little disagreeable as you can.
Get everything you want before you begin, and then wash
your patient quickly and gently, without leaving off in the
middle if you can help it, and take care not to wet the sheet
or nightdress here and there, so as to leave your patient damp
and disturbed, instead of refreshed. It will be a distinct
pleasure and I'efreshment to some patients to have their face
and hands sponged occasionally i| it is skilfully done, without
any weiirisome fuss of preparation for the process which is
sometimes such an effort to those in a weak condition.
38 LECTUEES ON NURSING. [Lect. II.
The liabit of washing several patients in one water is so
exceedingly dirty, that I should hardly have supposed any
nurse would have dreamt of doing such a thing did I not
know to the contrary. Children are victimized most in this
way, partly, I suppose, because the number to wash makes
it a serious piece of business in their wards, and partly
because they cannot object to it, as adult patients would
do. When you think how utterly distasteful it would be
to yoii to iise water in which another healthy person had
previously washed, I hope you can conceive what it is for
sick people suffering from various diseases to be cleansed — if
we can call it so — in the same water. Such a proceeding is
not without risk either, and it is inexcusable for laziness and
the slovenly desire to save yourselves trouble in this respect,
to prevent your taking proper care of those dependent upon
you.
I have not said a word about the extreme importance of
keeping your patients perfectly clean, literally from their
heads to their feet, because I may take it for granted that
from the time when you first saw in the hospital how dirty
people can be, you would understand that it is a nurse's first
duty to pay constant attention to this essential of her patient's
health and comfort.
Now we come to another veiy important point in which
patients kept wholly at rest in bed are dependent upon you.
I mean the skilful placing and removal of bed-pans and othei-
utensils, and the care necessary for their perfect cleanliness
and immediate removal from the wards after use. I need
scarcely point out to you that to keep the air of a sick room,
and still more of a ward, as fresh as it should be, great at-
tention must be paid to the immediate removal of all excretions
and other offensive matters.
The use of any chamber utensil without a lid is quite
inexcusable, and even with a lid it must under no circum-
Leot. n.] LECTURES ON NURSING. 39
stances be allowed to remain for a moment in the ward after
the patient has finished with it. If you have any doubt in
your minds as to the absolute necessity of this rule, look at
the inside of the lid when it has been iu use for a few
minutes. You will find it covered with condensed offensiA'-e
moisture, which, if the lid had not been there, must have
passed into the air, perceptibly poisoning it. It is impossible
to be too particular about this rule. It is very important for
yourselves, as the chief risk of nurses taking the infection
from some diseases lies in this direction. It is more con-
siderate for the feelings of the patient on whom you are
attending, and the others in the ward, and it is essential for
the ventilation. In many cases it is best to have some dis-
infectant at the bottom of the utensil before it is used, and in
almost all cases a little clean water should be put there. It
absorbs smell, and enables yQu to clean the vessel with greater
facility.
If ever the choice of lids rests with you, there can be no
doubt that earthenware is the cleanest material. The dis-
advantages of them are that they are rather noisy, unless
gently handled, and they are liable to breakage. But they
are certainly best, because earthenware does not become
saturated with matter as unglazed wood is apt to do. The
lids should be kept as scrupulously clean as the utensils
themselves, and no really good nurse will ever be un-
mindful of these details, or think them beneath her. Great
care must always be taken to keep the uinne bottles also in a
condition of perfect cleanliness. ' It is only those who have
not thoroughly understood the subject who think *' it does not
matter."
In well-managed and efficiently nursed wards no chambers,
even when clean, should ever be kept under the patient's
bed in the daytime. I never want you to sacrifice the
patient's comfort, or the utility of any aiTangement, merely
40 LEOTUEES ON NUESING. [Lect. II.
for the sake of appearances ; bat, on the other hand, it is a
pity to sacrifice appearances more than is absolutely necessary.
Besides, keeping unsightly articles about in the ward, even
when they are in a sanitary condition, increases the risk that
they may not be removed with the same promptitude when
they ha\^e been used, as they would be if fetched at the time
they were required.
I see no objection to the habit of placing clean chambers
tinder each bed when the ward has been duly settled for
the night. The best custom is for the day nurse or pro-
bationer to carry out this arrangement the last thing before
leaving the wards. It is the work of the night nurse or
probationer to remove them in the morning, when she attends
to any special instructions given in reference to individual
cases in respect to the saving or measurement of urine or
faeces, and this rule prevents any difficulty or mistakes in
getting a clear report left for the medical officer. It is the
duty of the day and night staff of nurses to leave the
utensils perfectly clean for each other. Under no circum-
stances, day nor night, should bed-pans or slipper bed-pans be
allowed to remain in the wards. I earnestly hope you will all
take great pains with yourselves about being absolutely
trustvvorchy in these details. The necessary care involves
constant trouble, but that must never deter a conscientious
nurse from being scrupulously careful about these things.
The bed-pan should be warmed, in cases where the
patient is very sensitive to chill, by placing a little warm
water in it prior to using it. The nurse must remember to
wipe the edges afterwards. The bed-pan should be oiled for
those cases where there is much perspiration, as in rheumatic
fever, for instance. So much real pain and discomfort can
be spared to patients by a skilful nurse, painstaking in these
respects.
For patients who are able to raise themselves a little, you
Lect. ir.] LECTURES ON NUKSING. 41
should take the utensil in yoar left hand, and put jour right
hand gently and firmly under the patient's back, Avith the
palm next to the patient's skin. If the patients are weak, it
will give a sensation of support, and Avith a little practice
this alone will enable you to know Avhether the vessel is in
its proper position. It is so hard upon the patients in their
weakness to be left in a damp, uncomfortable condition
through the ignorance or clumsy carelessness of the person who
ought to be their greatest help. If patients cannot raise
themselves in the least, always ask another person to help
you in placing them on and taking them ofE the bed-pan, and
do not attempt to push it in or drag it out by main force. In
the delicate condition which the skin of such patients is
certain to be in, that alone is sufficient to induce a bed sore.
It is no proof of a nurse's skill to do badly herself what it
takes two people to do well, and even private nurses can
generally procure the slight assistance necessary for these
occasions.
If a bed sore exists, and the dressings ai*e soiled and have
to be removed at the same time, remember that a nurse must
take them up Avitli her forceps, and burn them at once, not
leave them to stop up pipes, as is often too caxelessly done.
The constant keeping of your patients dry and clean is
most important, for many reasons that I need scarcely pause
to point out to you — who must already know something of the
matter — whether they are in a condition to call your at-
tention to their wants or not. This is one of the many dis-
agreeable duties which fall to your share, and which for that
reason demands the utmost delicacy and kindness fi'om you.
Some patients are so considerate that it is almost a pleasure
to attend to them, and othei'S so careless or oblivious of the
trouble they give that it is difficult to be patient with them ;
but you will remember that the cultivation of a nice habit in
this respect is invaluable to yourself, and Avill help you to get
42 LECTURES ON NURSING. [Lect. II.
throngli your trying work creditably. There have been too
many nurses careless of the distress they may cause their
patients by keeping them waiting for the assistance of which
they are in need. The only comment I can make upon this
is the very obvious one that the woman who could do such a
thing knowingly inust indeed have mistaken her vocation.
And, finally, we come to the mental rest which a true
nurse will aiford to her patient, and a very important point
this is, though it is more difficult to define than the practical
duties.
You want to "think for" your patients, and not leave
them the responsibility, which they will feel, whether ac-
knowledged or otherwise, of thinking for themselves. Do not
answer them impatiently, and tell thffli it is " your business "
if they venture to remind you of anything, as I am sorry to
say I have heard an impatient nurse do, but still try and
think for them so carefully that they shall feel a sort of
restful confidence in you. That in itself is a tangible help to
a very weak patient.
To this end you must strenuously cultivate a self- con-
trolled manner. It is no excuse for exciting your patients to
say that you were " all in a hurry," or that you " never gave
it a thought." A nurse who screams because she is a little
startled, who flies aimlessly about in all directions if she is
asked for two or three things at once, who says by way of
explaining why she lost her head in an emergency that she
was " all in confusion," has much to learn. Why should you
be " all in confusion "whatever happens ? Is it not because
you do not know any better ? It does require practice, but
self-control must be gained if you are to be thoroughly
efficient. Moreover, a want of self-control is selfish, as show-
ing that you do not put your patient first. It is ignorant,
too, I am afraid; showing great want of "training." How
many of you will let me say by-and-by that you are calm,
Lect. II.] I.ECTUKES ON NURSING. 43
quick, quiet, gentle nurses ? Noio you are at tlie beginning
of your training, and I do not want to expect too much, of
you, but I fear that it has to be acknowledged of many
nurses, new and more experienced, that they are often noisy,
bustling, excitable, and veiy easily flurried.
Unless you have been veiy ill yourself, you have no notion
how weak patients depend for their own courage on their
nui'se's strength, and a quiet, confident manner will, be an
immense help to them. Even if you feel excited, or confused
and worried, try hard not to sJiow it.
You must cease to look upon this failing as excusable,
but remember it is a grave defect in itself, and if you do not
acquire this calm manner by the end of your training, you
will never be first-rate. How I should like all nurses to
become illustrations of a beautiful description I once read,
though at this moment I cannot recall by whom it "VA'as
written —
" A calm, huelied presence
Bringing rest — to those who felt and understood
The dignity of womanhood."
In providing perfect rest, remember that much depends,
too, upon night nurses. I cannot reprehend too strongly
the deplorable custom that was once so prevalent in the
hospital world, and which, I fear, is by no means extinct
even yet, of putting the least efficient and the least depend-
able nurses on night duty. It is not too much to say that it
was a common practice to put persons who were acknow-
ledged to 'be totally unfit for day duty, in charge of wards
at night, when, as all of you know, the responsibility which
rests in their hands is at least double that which, in the
ordinary course of things, can devolve upon any staff nurse
on day duty, I have no doubt that this plan originated partly
in the difficulty of finding night nurses, partly because culpable
neglect of duty was more likely to remain undiscovered in
44 LECTURES ON NURSING. [Leot. II.
most cases by night than by day, and therefore gave less
trouble ; but we can scai'cely realize too strongly how wrong
and unjustifiable such a system is. This is scarcely the
occasion for me to enter into the many reasons why I dis-
approve of allotting the work of day and of night nursing to
an entirely distinct and separate set of staff nui'ses. With
a few exceptions, I believe it is a mistake for all concerned ;
but I may well take this opportunity of impressing upon you
the importance of the duties and of the responsibilities which
rest in the hands of night nurses. The punctual administration
of food and medicine — the careful observation of symptoms
upon the immediate treatment of which life may depend —
the living and the dying are literally left in charge of the
night nurses, and are often, too, wholly dependent upon them.
It is a great trust, and I should like to have the comfort of
feeling that all of you thoroughly realize this, in order that
you may spare no effort to make yourselves worthy of it.
Those of you who may have read that beautiful poem of
Mrs. Hamilton King, '• The Disciples," cannot fail to have
been struck with that wonderful " Sermon in the Hospital."
I am particularly glad to learn that it has now been published
separately from the complete volume, and is to be had as a
small pamphlet. I make this known to you, because I think
all nurses would be the better for reading it, and would
probably find their sympathy with suffering increased ; and
1 refer to it especially at this moment for the sake of two
lines there applied to the sick, but Avhich night nurses may
well refer to themselves, and find help in the thought —
" God gives His angels charge of those who sleep,
But Ho Himself watches with those who wake."
Often and ofteii I think of this when I have finished my
x'ound of the wards, and go to bed fully realizing the long,
anxious Avatch before some of you. We know that a very
Lect. II.] LECTUBES ON NUESING. 45
real blessing rests upon all loyal, faithful service ; aud I only
remind you of it that you may do your work in such a -way
as to make this blessing your own.
" The noblest service comes from nameless hands,
And the best servant does his work unseen."
I have to-night attempted to point out the chief duties of
a nurse in connection vpith the treatment of complete genei-al
rest, when it is ordered for a patient under her care. I speak
of very small details, because it is these which might not
otherwise occur to you ; and yet the omission of them would
at once show an experienced observer that you were not doing
these simple, every-day duties with that finish which should
characterize every item of a trained nurse's work.
Next time we will consider what a nurse has to keep in
remembrance in connection with " partial rest," as supplied
by splints, bandages, mechanical supports, and other local
appliances, in caiTying out that system of treatment.
46 LEOTUEES ON NUKSING, [Leot. III.
LECTURE III.
Throughout all these lectures^ I am anxious that you should
keep in your mind the leading idea that nurses are active agents
in cai-ryiug out a scientific system of treatment laid down by
the doctor. I want you to look at your work from this point
of view, because I am confident that it will be of service, both
in showing what your own line is, and what are its limits,
and also in helping you to keep to them.
I told you last time that treatment presents itself to us
under one or more of the three following aspects. First, to
provide an-antidote to any poison, and to remove all sources
of harm; as, for instance, in removing a person who was
suffering from the ill effects of an infected neighbourhood
to a healthy locality, or giving up an occupation which pro-
duced disease. Secondly, to put the patient in the most
favourable position for self-cure; as, in the breaking of a
fractured limb, at rest in the right position, and leaving
Nature to effect her own cure without interruption. Thirdly,
to aid in treatment by drugs which experience or experiment
have shown to be efficacious — as in the case of certain appli-
cations for skin disease — which may be all the treatment
needed. I endeavoured to explain that one of these methods
of treatment may suffice — as in the illustrations I have just
given you — or that a combination of all three may be desirable
— as in a case of rheumatic fever, for instance, when it would
be necessary to remove the patient from all influences con-
sidered to be conducive to i-heumatism, whether it was the
Leot. UI.] LEOTUEES ON NUKSING. 47
locality in whicli the patient lived, or the kind of work in
which he was engaged. During an acute attack of rheumatic
fever, it would be necessary to keep the patient in a suitable
temperature at rest in bed between blankets ; to give suitable
diet ; and, finally, to aid in the treatment by such drugs as
the doctor might consider most likely to be beneficial to the
case ; and thus all three methods of treatment would be
employed. The more you reflect on the subject for your-
selves, the more clearly you will see that all treatment does
present itself to us under one or more of these aspects.
You are aware, also, that when we speak of therapeutics
we mean treatment ; and that ti-eatment consists in the appli-
cation of natui'al agents, such as rest, cold, heat, and others
too numerous for us to enter into now. We divided the first
of these into two headings — general rest, as applied to the
whole body, whether complete or comparative ; and partial
rest, as it is prescribed in the form of sphnts, bandages, and
other mechanical supports, to meet local emergencies.
We fully entered into the first half of the subject last
time, and to-night we will first turn our attention to the
details it is desirable you should know in connection with
the second part of this subject ; and this brings us to the
question of partial rest, as supplied by splints, bandages, and
strapping.
I do not propose to weary you with verbal descriptions
of the different kinds of splints, the names and patterns for
various purposes used in this and in other hospitals ; these
can be learned best in the wards ; neither have I forgotten
that in the course of another two or three months you will
be having the benefit of most interesting and useful lectures
on " Surgical N'ursing." But there are a few small points
that surgeons seldom remember to mention; perhaps they
fancy that a knowledge of them comes intuitively to nurses,
though we all know this is not quite the case.
48 LECTUEES ON NURSING. [Lect. HI.
It is especially the imrses' business to take pains with
tlie cleansing and padding of splints. There are innumerable
kinds of splints made of various materials — wood, metal,
gutta percha, leather, and other new and improved materials
are constantly being introduced. In cases of emergency,
broomstick handles sawn in two, and newspapers, have served
the purpose when nothing else was to be had. I once heard
of an old copy of the Times newspaper being folded up and
used most successfully as the splint for a fractured humerus
by a skilful surgeon, when the accident happened far from
civilized regions, and no better appliance could be obtained.
I mention this, though, merely as an interesting incident, not
with the anticipation that you will ever be expected to pre-
pare newspaper splints. The names of the splints most used
for their respective purposes, and the comparative advantages
and disadvantages of different kinds — any special points to
remember in the padding of any of them — are all matters for
practical experience in the wards, and it is only in this way
that the requisite knowledge can be acquired. To give you
minute theoretical instruction on these details would be an
utter waste of time, so I shall confine my remarks on the
subject to a few general and important statements.
You can scarcely be too careful about cleansing and dis-
infecting all splints that are to be used again. Never put
them away dirty by any chance, and think you will attend
to them when you have more time, and that it will be all
right if you can manage to get them ready somehow before
they are wanted. They may be Avanted suddenly, when
perhaps you are not there ; and it is infinitely better that
you should have the extra trouble of cleaning them again, if
they have time to get soiled before they are wanted, than
that any risk should be run of infecting a patient by the
application of a splint that is not absolutely clean. I need
scarcely point out to you how I'eadily the contagion of
Lect. III.] LECTURES ON NURSING. 49
erysipelas or pysemia may be conveyed from one patient to
another by an uncleansed or inefficiently cleansed splint. It
is not too mnch. to say that lives may be, and, unfortunately,
have been, lost, solely through the carelessness — I may fairly
say, the unconscientious carelessness — of nurses indifferent
to, or ignorant of, the danger. After all, ignorance is not
a very adequate excuse, if we hold a position which makes
us, under certain conditions, responsible for the lives of
some of our fellow- creatures. It is terrible that some are
sacrificed mainly through such avoidable causes. The more
we think of the responsibility attaching to a nurse's work,
the more vividly we must realize the grave importance of
understanding as much as we can about everything we have
to do, aud the reason why these apparent trifles demand so
much care and attention. Pat plenty of carbolic acid in the
water with Avhich you cleanse splints, whether the case for
which they have previously been used makes you think this
precaution specially necessary or not.
Now, with regard to the padding of splints, as far as
possible, you must take pains to pad to suit the ideas of the
surgeon for whom you are working. Some give the prefer-
ence to rather thick pads, some like them much thinner ; all
expect to have them, evenly made, one of the objects in using
them being to apply equal pressure. Soft old linen is the
best material for covering pads, but as large hospitals are
but insufficiently supplied with this, we are obliged to use
unbleached calico. Some prefer making the entire pad of
blanket ; but this material is not conducive to cleanliness, as
you will soon perceive for yourselves if you ever have them
used in wards in which you are working. A mixture of tow
and wool is generally used to stuff pads. All wool is said
not to have sufficient " spring " in it, besides being extravagant.
Tow is not sufficiently soft to be employed alone. All lumps
must be carefully avoided, whatever material is used. Nothing
R
50 LECTURES ON NURSING. [Lect. III.
can be more admirably adapted to its purpose than the padding
■wool sold especially for it. It is very expensive, but it is
excellent ; and in using it you must combine economy with
extreme care not to run the slightest risk for the patients, by
making up pads with a single morsel of padding wool that is
not as safe for the purpose as that which comes straight out
of a new packet.
In many cases pads are covered with gutta percha tissue,
though this occasionally irritates the skin. The object of
waterproof covering for splints is to keep them clean and
diy, notwithstanding applications of a moist and greasy
nature. Oiled cotton can also be used, and it does not
pi'oduce the irritating effect of gutta percha tissue, but the
disadvantage of it is that it is not very soft to place next the
skin. One point you should be careful to remember in
padding all kinds of splints, and that is to make the pads
sufficiently large to thoroughly cover the sides of the splints,
and not leave the hard edges without this protection. If
any surgeon objects to this, you must at once endeavour to
meet his wishes, but such objection will be the exception and
not the rule. The pads should be sewn on with long even
stitches, but if they are wanted in great haste or if additional
pads are suddenly required — as they sometimes are in the
operating theatre, for instance — a piece of strapping quickly
wound across will serve to keep them in place admirably. In
applying or helping others to apply splints always have cotton
Avool at hand ; it is often serviceable in preventing or
relieving pressure. If patients complain of much pain after
the application of splints, be sure and notice if there is much
swelling or discoloration of the adjacent pai'ts, and call the
sister's attention to it at once ; though of course you would
not think of loosening the bandage on your own responsibility.
Plaster of Paris, starch, gum and chalk, silicate of potass,
applied with bandages are light forms of splints that you
Lect. m.] LECTUEES ON NURSING. 51
will often see put on in the wards. They keep an injured
joint in position in a form least inconvenient to the patient
when he begins to move about. A flannel or domette bandage
will always be applied to the limb before the other, and some
cotton wool is frequently required. I will not enter into
further details of how to prepare these, as you will all be
able to learn it better practically in the wards. If patients
are going about much with these splints on, the white of an
egg painted on as a varaish is useful to prevent chipping.
Sand-bags are extremely useful to keep injured limbs still and
in position ; they should be made of tick, such as is employed
for making beds, because it is strong and close in texture, and
sand is very heavy. The sand-bags should then be covered
with mackintosh, oiled cotton, or gutta percha tissue, to keep
them dry and clean, and finally it is a refinement of nursing
to cover them with little cases of unbleached calico that are
made to come on and off as pillow cases do ; they are then
ready to be supplied clean for each patient, or whenever neces-
sary, and look neat and " finished " in the bed. Be sure in
making sand-bags that the sand is thoroughly dry.
Strapping is applied to various parts of the body by way
of affording support and even pressure. The strapping
should be carefully ruled before cutting to ensure evenness,
and the strips must be cat the required length and width.
The nva'se must be quick and attentive in handing the
surgeon the strips as he is ready for them, duly wanned by
placing the non-adhesive side of the plaster across the hot
Avater strapping tins. Some surgeons prefer the sti-apping
dipped into hot water, but they will tell you so in these
instances, for this is exceptional, and the other method is far
cleaner and nicer for adoption as a general rule. Fractured
ribs are frequently treated by strapping the chest, to afford
support and secure the greatest possible " rest " to the injured
part. "With some surgeons strapping is a favourite form of
52 LECTURES ON NURSING. [Lect. III.
tx'eatment for ulcerated legs, and this reference reminds inc
to tell you that when you ai"e ordered to remove strapping
from wounds, you must be extremely careful not to drag
open the wound. In removing strapping from wounds you
should begin at both ends and work towards the centre of
the wound. This is an important point to remember, not
only for the sake of avoiding pain to the patient, but to
prevent all risk of breaking down or injuring any union that
may be taking place. An ignorant nurse removing strapping
roughly and clumsily may during the process undo the work
of weeks, so please do not regard this as a trilling detail.
If it falls to your share to apply strapping to an ulcerated
leg, remember you stand in front of your patient in the
same way that you would to put on a bandage. Then pass
the well- warmed strip of plaster under the limb, and apply
the middle of it to the back of the leg, bringing the ends
round the sides of the leg and crossing them over in front.
Each succeeding strap should overlap its predecessor about
one thii'd of its width. I dare say most of you have seen how
neat it can be made to look if it is skilfully done.
The strapping put on the leg to enable extension to bo
applied is often left to the nurse to do. A practical illustra-
tion of how it is done is better than a verbal description.
You must be careful to put on the strapping in such a way
as to avoid wi'inkles, and as far as possible to avoid pressure
sores. This point needs a great deal of attention, and you
must always see carefully if anything is wrong when the
patient complains of pain in this respect. A little piece of
wool under the heel or between the loose part of the strapping
may often save a great deal of suffering. It is a good plan
to cut a small hole in the loose part of the strapping for
extension, which comes over the ankle to relieve all chance
of pressure or friction there. Small pieces of lint shoiild
be neatly wound round the foot to prevent all avoidable
Lect. III.] LECTURES ON NURSING. 53
discomfort, and infinite pains must be taken to make every
ari"angement possible for the patient not to suffer any un-
necessary inconvenience, nor to run any risk of the treatment
of extension ha\nng to be given up in consequence of external
sores. Remember the weight must not be put on until the
strapping has had time to adhere firmly, A flannel bandage
is put on over the strapping. When the extension has been
applied you must lift the weights carefully before giving the
patient the bed-pan.
You must never ignore a patient's complaints of a splint
or piece of sti'apping being too tight. The sores which come
in consequence are often difficult to heal. Take care that
the sister knows of the complaint, that she may attend to it.
Of course you mnst not alter anything the surgeon has
applied without orders to do so. After plaster of Paris and
other bandages of the same description, swelling is apt to
take place, and you must notice if the part below the bandage
swells or becomes discoloured. Some patients will complain
of the least discomfort, and others are too patient to complain
readily, so a nurse must be watchful on these points.
To get off the dirty marks of strapping use a little oil ;
turpentine, of course, is effectual, but that is rather harsh ;
chloroform is also excellent for the purpose, but you would
not be likely to have it about for general use in the wards, and
it should be remembered that chloroform blisters some skins.
I may as well mention also that strapping is cut in a
special manner for cases of hare-lip. I should scarcely
succeed in conveying to you a clear idea of the arrangement
merely by a verbal description. You must take the earliest
opportunity of getting a pi'actical illustration in the wards,
and any private nurse who finds herself obliged to undertake
a case of hare-lip without previous experience should remember
to ask the surgeon how he wishes the strapping cut before
the operation begins.
5-1 LEOTUBES ON NURSING. [Leot. III.
Another method of cutting strapping is useful in cases
where it is desirable to afford support and at the same time
to keep an outlet for the discharge. This is known as grid-
ii'on strapping, a portion of the strapping being cut into
strips in a manner suggestive of the name.
When antiseptic dressings have to be kept in place with
strapping some surgeons prefer that the strips shall be
moistened by dipping them into a hot solution of carbolic
acid (1 to 19) instead of warming them in the usual way.
Arm, leg, and general bed- rests of various kinds must
be adjusted to suit each case in the manner that will be
shown to you in your practical work, and you must apply
such common sense and intelligence as you are fortunate
enough to possess, to the complete understanding of the
principle and skilful adjustment of such appliances. I should
mention in connection with the use of bed-rests that the
tendency which weak patients have to slip down in the bed
when the upper part of the body is raised against a bed-rest
is frequently a source of discomfort, and the convenient, in-
expensive footpiece, with pieces of webbing attached to enable
it to be graduated in conjunction with the bed- rest to the
needs of the patient, which has been invented by Mr. Newton
Nixon, of University College Hospital, seems likely to prove
of great service.
The application of slings is frequently left to the nurse,
without any special directions being given ; so there are two
or three facts in connection -with their adjustment that it
may be useful to you to know.
In injuries to the arm or hand, in neai-ly every case, the
sling should support the whole of the forearm, including the
elbow. The only exception to this would be a fracture of
the upper arm, in which case the pushing up of the elbow
would have a tendency to displace the fracture, and it is
better to employ a narrow sling for the wrist or hand only.
Lect. III.] LECTURES ON NURSING. 55
To suppoii the foot, the sling should be placed round the
neck. For slinging up the arm or foot in a recumbent position,
webbing should be attached at intervals to the cradle, which
is placed over the injured limb to relieve the pressure of the
bedclothes. With i-egard to the varying height at which it
should be slung up, I can only recommend you to carefully
note how the surgeon places the limb when he slings it up
in the first instance, and endeavour to keep it in exactly the
same position.
A three-cornered bandage can be used advantageously as
a sling, and it can also be adapted with excellent effect to
most purposes for which ordinary bandages are applied. This
is called the Esmarch bandage, from the name of the inventor.
You must get taught in the wards the various methods in
which they can be applied.
This leads us up to the subject of bandages — one of
universal interest to nurses. I only propose to-night to deal
with the theory of bandaging ; that is, to lay before you
certain fixed principles for you to keep in your mind as a
guide for the practical work.
I am anxious to point out to you that it rests much more
with youi'selves than you appear to think to attain proficiency
in bandaging. You hope to learn that amongst other nursing
accomplishments; but how, where, and when, probationers
leave to circumstances in a manner that is, I think, rather
disappointing, and certainly unwise for yourselves.
I do not attach much value to bandaging classes, because,
as every learner cannot I'eceive individual attention at once,
it entails considerable waste of time, and there is no single
advantage to be gained by them that cannot equally be
obtained in the wards.
I most strongly recommend you to avoid practising on lay
figures and blocks, if you wish to become good bandagers.
The sensation — if one may so speak — of handling stifP, un-
56 LECTURES ON NURSING. [Lect. III.
yielding material, however well shaped to the- limb, is so
different to the comparatively elastic touch of living muscle,
that my observation in this matter has led me to the con-
clusion that practising bandaging on lay figures is not only
undesirable, but harmful. This is my opinion on the subject,
and it is due to you that I should put before you the result
of my experience ; but I need scarcely say that you are not
bound to adopt my convictions for your own. At the same
time, I would not be understood as condemning the practice
of being shown the manner of applying any particular
bandage, or of just learning the actual method of the appli-
cation on a lay figure yourself. The custom I deprecate is
practising, with a view of obtaining proficiency, on a lay figure,
under the impression that it is as satisfactory for the purpose
as a living subject.
Choose your opportunities of practising and of being
shown, but loolc out for them, and do not wait, as children
might do, for others to be more aioxious to teach you than
you are to learn. If you are eager to learn, and exercise a
little discretion in the time when you ask to be taught, you
will find no lack of ready and skilful teachers. Many of you
could improve the time when you have what we are apt to
call an uninteresting special case on your hands, by practising
on any good-natured convalescent patient, who is inclined to
be amused at the proceeding, or on another nurse or pro-
bationer, who may have a few minutes to spare. I know
that for the most part your time is closely filled up, but I
am confident that every one of you will find innumerable
opportunities if you care to take the trouble. Some of you
on night duty waste valuable time and chances in wards
where there are two of you on duty, and there are occasional,
if rare, half -hours when your patients are Avanting nothing ;
and it is pleasant to me to know that nowhere could you find
night sisters more cordially interested in and desirous of
helping you.
Lect. III.] LECTUEES ON NURSING. 57
Of course, put your patients and your work for tliem first
— a long way first — but do not forget that self-improvement
in the branch of education that you have come here to study
is also a duty that you have no right to neglect. I do not
want you to become more selfish, but I should like to see the
majority of you a degree more eager to " train yourselves."
I say this without reservation, having too much, confidence
in you to fear that you will misintei-pret my meaning. Nothing
but constant practice can perfect you in any mechanical
accomplishment ; and I simply want to put before you that,
if you cannot take the personal trouble necessary, you must
inevitably remain more or less ignoi-ant. You must not
imagine that bandaging is only to be thought of in surgical
wards. On th.e contrary, you had better practise on sound
than on injured limbs. When you have to take the latter in
hand, it is well you should know how to manage them.
Now that I have said so much, perhaps I had better
mention that I am not desirous of this kind of thing being
done too obtrusively and at all seasons in the wards. I should
be sorry to come across visions of probationers bandaged up
b}' each other in all directions, and for you to be under the
impression that this was my wish ! I have not had sufficient
evidence of energy in this respect. My impression is, that
the idea of getting yourselves taught bandaging has not
occuiTcd to many of you, and I hope now that many will act
on my suggestion ; only do not go to the other extreme.
Most nurses are, or should be, familiar with Berkeley Hill's
work on the " Essentials of Bandaging," and I am glad to
quote some of his clear and condensed instructions to you
to-night.
Bandages are made of ordinary flannel, domette, wn-
bleached calico, linen, muslin, or gauze of various kinds. In
preparing them for use, remember that selvages must always
be removed, and, of course, avoid joins as much as possible.
58 LECTURES ON NURSING. [Lect. III.
Where economy or any other reason necessitates them, be
sure to make the seam as flat and smooth as possible, and
do not use big knots in your cotton. All bandages must be
i-olled tightly, to enable them to be satisfactorily applied.
The lengths vary from six to twelve yards, generally some
length between these two measurements. It is not a proof
of good bandaging to see how much bandage you can wind
on, but rather, within certain limits, to ascertain how little
will answer the purpose satisfactorily, without cumbering the
limb unnecessarily. At the same time, it is often essential to
extend the bandage considerably beyond the exact spot which
renders its application necessary, to prevent the swelling of
adjacent parts. Endeavour to understand as far as possible
with what object the bandage is ordered. It may be merely
to secure a dressing being kept in place ; it may be to supply
firm support ; it may be to check hemorrhage, or for some
other reason. But, in any case, remember to keep the primary
object in view, whatever that may be ; next, have due regard
to the comfort of the patient ; and, finally, to the neat appear-
ance of your bandage. Bandages are of various widths,
according to the purpose for which they are required.
Head-rollers are usually about 2 inclies wide
Arm-rollers „ „ 2i „
Leg-rollers ,, „ 3 „
Eib or chest rollers ,, ,, 6 ,,
Toe or finger rollers ,, „ only f or i an inch.
Occasionally double-headed rollers are required, i.e., the
bandage is rolled up from both ends towards the centre, so
that you have, as it were, two rollers joined together to woi-k
with. This is convenient for the capeline and some other
bandages.
When you are going to apply a bandage, place yourself
opposite the patient, not by the side. Always make a firm
and fixed beginning for a starting-point, not on the place for
Lect. III.] LECTURES ON NURSING. 59
which the bandage is needed, but beneath. " When apply-
ing a roller, it is best to begin by placing the outer surface
of the roller next the skin. . . . The bandage should be
carried from the inner side of the limb by the front to the
outer side." Bandage upwards. The turns must never be
made over a prominence of bone. There are three different
tarns, the simple spiral, the reverse, and the figure of eight.
The spiral bandage is [sufficient when both edges of bandage
can lie evenly on the surface of the limb, but when the limb
.enlarges too fast for this, the turn must be interrupted, and
brought back by a reverse ; or, if over a joint, for instance,
by figure of eight.
At the moment of reversing, hold the bandage quite
loosely, and the thumb of the unoccupied hand must fix the
lower border of the bandage at the highest point of the turn,
while the roller is turned over in the other hand and passed
downwards to overlap the previous turn evenly. All the
reverses must be candied one above the other, along the
outer side of the limb, and only employed when necessary.
Figures of eight are made exactly as their name implies,
by passing the roller alternately upwards and downwards as it
enwraps the limb. They are adopted where the enlargement
is too great and irregular for reverses to lie evenly, as the
ankle, the elbow, or the knee. It is of the first importance
that bandages should be adapted to the object for which they
are employed, Avhatever that may be. They must not be too
tight over dressings. They must afford steady, even pressure,
9,nd not be tight and loose alternately.
To get reverses always outside limbs, you must learn to
bandage with both hands with equal facility. But do not
make turns over a wound when it can possibly be avoided ;
for instance, if the ulcer is on the outside of the leg, make
your reverses inside, avoiding the prominence of bone. The
patient must always be thej^r*^ consideration, and every other
60 LECTURES ON NUESING. [Lect. III.
nursing quality comes after that. Nothing but constant
practice can teacTi you Iioav to do the various kinds of bandages
Avith skill, neatness, and finish. It rests with all probationers
who pass through our training school to maintain the i*eputa-
tion of being good bandagers for London hospital nurses.
The T bandage is made with two pieces of bandage,
the end of one joined to the centre of the other, which
should be long enough to tie round the waist and fasten in
front ; the other end should reach from the centre of the
back, under the perinteum, and up to the waist in front.
This piece may be left entire or slit into two tails, which can
be fastened separately over each groin. This is a most useful
bandage for keeping applications in place.
The same may be said of four- tailed, six-tailed, and many-
tailed bandages. These are made by joining the requisite
number of strips of bandage, slightly overlapping each other,
on to a central piece of bandage. The particular advantage
of the many-tailed bandage for those cases to which they are
applicable is that the dressings can be changed without
moving the limb, and thus much pain, and possibly some
increase of iiijary, may be spared to the patient.
The capeline bandage for the head is not infrequently
used, and is serviceable occasionally. There is nothing
specially to mention in the theory of its application, and you
must try and get practical illustrations of it and individual
practice in applying it in the wards.
The single and double spica bandage is a figure of eight
applied to one or both groins.
A bandage for the jaw has a small slit made lengthways in
the centre to support the chin, and the ends are slit a little
way down, so as to fasten partially at the back of the head
and partially at the top, as this serves to keep it in place.
Rib rollers are the best kind of bandage with which to
apply jacket poultices, but a broad piece of calico, rather
Leot. m.] LECTURES ON NURSING, 61
more than the depth of the poultice, brought from under the
back, and fastened with strings or safety pins in fi'ont, and
with two strips of bandage sewn at the top of both sides at
the back, and brought over the shoulders, to fasten with
safety pins in front, will keep the poultice securely in position,
and be less fatiguing for the patient when the poultice is
renewed than the rolling and unrolling of a bandage on each
occasion. This i-eminds me to tell you that in taking off a
bandage you should gather it promptly up in your hands as
fast as you unwind it, and not leave it hanging loose, to drag
more or less by the yard, as you remove it. I think there is
nothing else of importance for me to tell you about the
principles of bandages. I can only hope that you will all
endeavour to become proficient in practice.
I will take this opportunity of making a few observations
to you on the subject of surgical dressings generally. I am
aware that, strictly speaking, they can scarcely be considered
under the heading of partial rest, the question to which we
are turning our attention to-night ; but in the practical part
of a nurse's work the preparation and application of dressings
is very closely allied to that of splints and bandages, so I
think that such a digression is not unpardonable.
When I speak of surgical dressings, I do not mean that I
am going to tell you minutely why various dressings are
used, what are the various characteristic appearances of
different wounds, nor what is implied by the well-known
expressions commonly used in reference to them, for this wide
subject will be duly set before you in detail in the course of
lectures which will immediately follow mine ; but the points
I wish to speak of in connection with this subject are those
which surgeons commonly take for granted that nurses know
by instinct, or which they have never happened to notice
themselves.
I need scarcely tell you that no amount of theoretical
62 LECTURES ON NURSING. [Leot. lit.
instruction will be of the same value as the practice you
get daily in the wards ; but I am confident that a com-
bination of theory witb the practical experience you are now
gaining will not only enable you to learn better, but to learn
quicker, because you will be able to profit to the utmost by
what you see and hear, instead of carrying out the duties
which fall to your share quite mechanically. Of course do
what you are told with implicit obedience, whether you under-
stand the object with which the orders are given or not ; but
the more you understand, the better it will be for yourselves
and all concerned, provided, of course, that you are careful
never to obtrude your knowledge.
I am anxious that in teaching you, and in every arrange-
ment made for your efficient training, you shall \now fully
everything which a good nurse ought to know and do
in every branch of your profession ; but I am also most
anxious that you should carefully guard against every
temptation to display that knowledge, except practically.
The pei'fection for a nurse is to know everything that she is
wanted and expected to know, and to let every one under
whom she works be able to safely take it for granted that she
possesses the requisite knowledge. It is never necessary for
a nurse to say, " I can do this and that," or " I think this
and that," unless she is asked the direct question. The
golden rule for nurses to remember is to "state facts, not
opinions," and I pause to remind you of this, because we
are more likely to fall into this error when our knowledge
is comparatively new, as it is with probationers, than when
we have become so familiar with nursing details that we
can scarcely believe there was ever a time when we did
not know them. I want you each to cultivate for yourselves
any little habit of finish or neatness that I may now speak
of, so that from sheer custom it would be awkward for you
to do things in any other way. By-and-by, you will wonder
Lect. III.] LECTURES ON NURSING. 68
that you ever needed to be told of them, only it will be
your turn to teacb others then, I hope, and you will see over
again that a knowledge of nursing does not come instinctively,
and will, I trust, be patient and painstaking when it becomes
your turn to teach.
In a surgical ward, when the general work is straight, the
next thing a nurse has to think about is getting the dressings
ready. There are so many different dressings in different
degrees of favour with different surgeons, that it would be
impossible to speak of all of them in detail. A nurse should
endeavour that every case should have the dressing needed for
it waiting by the bed for the dresser or the house surgeon.
In an efficient ward they should never have to wait, except
when such fresh things are wanted that a nurse could not be
supposed to know about them beforehand. Of course in
children's wards you will take care that the waiting dressings
are not left within their reach. It is either laziness or great
want of thought on the part of a nurse to wait until the
dressings are asked for, because " perhaps they won't be
wanted," or they are " not quite sure that ' the dressing ' will
be done to-day." That is a slovenly sort of way for a nurse
to get into, and I am always sorry when I hear of any instance
of the kind. Besides, uncertainty as to what the surgeon
or dresser may decide to do, does not alter the fact that it is
a nurse's business to have everything in her department quite
ready. Of course, if you are uncertain what to do, ask the
sister, or, if she gives you any direction, you have only to
follow it ; but whilst I am most particular that you should
' always \ refer to the sister, and not take things upon your*
selves, I am afraid you often make her work heavier than it
need be by throwing upon her the responsibility of reminding
you of eveiy little thing. There is great scope for careful
observation in this getting ready of dressings, and any trouble
you take in this respect will repay you greatly.
64 LECTURES ON NURSING. [Lkct. III.
Ill doing dressings yourselves be quite sure that you liavo
everything ready before you begin. It does not matter how
long or how short a time you may have been in a hospital,
but you cannot consider yourselves " trained " while you
find that you have to leave off in the middle and fetch what
you knew beforehand you would require if you had only
troubled to think about it. You will need an empty receiver
ready for the soiled dressings. I have been surprised before
now to see these soiled dressings thrown about on the sheet,
the check, or even the floor, just because the receiver was not
at hand for the purpose. It does not save trouble, for, of
coarse, tbey have to be picked up again, and it is obviously a
very objectionable and dirty arrangement.
Each of you should provide yourselves with a pair of
dressing forceps, scissors, and pins, and be sure you accustom
yourselves to use the forceps, and not your fingers, for touch-
ing those dressings which are in contact with the wound or
soiled with discharge. I have already warned you as forcibly
as I can on the subject of covering up your fingers if you
have the very tiniest pin prick on them. You all know how
quickly the worst forms of poison may be taken into the
system in this way, and I can only x'epeat my former injunc-
tion, and remind you that a nurse cannot be too careful o£
her hands. You must also be extremely cautious not to put
your fingers to your face, or eyes, or mouth, when you are
doing dressings, until you have washed your hands.
In some hospitals it is the custom to use the irrigatoi"
for washing wounds ; in some the glass syringe ; in some
an ordinary syringe with a glass nozzle fitted on to go in
the wound, and in some hospitals these are only used when
the house surgeon ordei-s it, and other cases are washed
with tow, cotton wool, lint, or linen. The one thing which
should never be used for this purpose is a sponge, because
of the difficulty of effectually cleansing it. For private
Lect. III.] LECTUKtlS ON NURSING. 65
cases the objection to this is lessened, because, as you
would be using this for one case only, there would be no
risk of taking any poison from one wound to another, and,
of course, you would keep it soaking in some disinfectant;
but when you have accustomed yourselves to using little
pieces of cotton wool, you will certainly prefer it. I must
not forget to speak of the way in which this should be
done. Nearly all wounds now are cleansed with, warm water,
to which a little carbolic lotion has been added. Now there
cannot be any necessity for dipping the piece of cotton
wool which is soiled with discharge into tbe basin or the
receiver which contains the water that you are using for
this purpose, and thus soiling the whole of the contents.
The next time you wipe round the wound, neither the wool
nor the water will be perfectly clean. You should take a
little piece of wool, soak it in and wring it out of this water,
and when you have used it, put it in the receiver which con-
tains the soiled dressings, and take a fresh little bit of wool
each time until you have finished the washing. Small pieces
of soft old i-ag Avill answer the purpose equally well if you
have a supply of them.
For washing a wound you should place a dressing tray or
a small basin, whichever appears more convenient, under the
limb, so that there may be no difficulty in keeping the bed
and the patient dry, and very often a mackintosh may be
wanted for the purpose also. In washing wounds avoid
touching the edges, as that gives the most pain. Wash round
them gently and firmly toioards and not aivay from the
centre of the wound, and if it is necessary to touch the
surface do it lightly. You will remove the stains of ointment,
etc., best by a quick circular movement, and the marks of
strapping can be removed with a little oil or turpentine, as
I have just observed ; but be sure, if you need to use the latter,
you keep it carefully away from the wound. Never let your
66 LECTURES ON NURSING. [Lect. lit.
patients be more exposed than is absolutely necessary for
doing tbo dressing ; see that they are comfortably covered
up, and not risking cold. The wound must never be left
uncovered. If you are cleaning it preparatory to a poultice,
cover it up with a little piece of wet lint or linen while you
are making the poultice, and see that the windows are closed.
For a recent wound cold water, sometimes iced water, is used
for cleansing it, for fear of renewing the tendency to bleed,
but for wounds of longer date, warm water is generally used,
as I said before. In removing strapping, I may remind you
again here, that you must take gi*eat care that you do not
undo much of the good that may have been done by pulling
the edges of the wound open. You should begin to take it
off first at one end- until you come near the wound, then at
the other, and finally with a little care you will be able to
remove it without hurting the wound in any way. When
you can, put the finger of one hand on the skin from which
you are removing the sti-apping, so that there may be no
*' tearing sensation '' for the patient. Never remove dressings
roughly when they are adherent to a wound. They often
become very stiff with blood and discharge, but you must
thoroughly saturate them with lukewarm water or oil, so as to
avoid tearing open the wound or breaking down any union
which may have taken place. You must be very gentle in
doing this, not only to prevent hurting the patient, but for
fear of the harm you may do by any carelessness in this
respect. When ointments or some liquid dressings are
ordered to be applied to sores, you must remember it is
useless to apply them over hard dry scabs. These must first
be removed, and the process of getting them off will be much
facilitated by the free application of oil, which softens them.
Remember that forceps, not fingers, must be used for the
purpose. Always keep the hair cut quite close near any
wound or sore place, or it will interfere in many ways with
Lect. III.] LECTURES ON NURSING. 67
the dressing. Be sure in dressing burns that you do not
expose the whole or much of an injured surface at one time.
The old dressings must be removed and the new ones replace
them by very careful degrees, not all at once.
Nurses in this hospital have seldom much to do with
preparing large quantities of zinc di-essing, but in private
nursing it would fall to their share, therefore I may as well
mention that it will greatly facilitate the pi'ocess of spreading
the ointment if you dip the spatula frequently into hot water.
The grease of the ointment of course will not mix with the
water, and the hot blade of the spatula will spread it more
quickly and smoothly. Zinc dressings should always be kept
ready spr-ead, and nurses should not get into the habit of
putting a little ointment on a piece of lint just when it is
required. It is wasteful, and the application is not in such
good condition. When you are told to apply zinc or any
other stimulating dressing, you must remember that it is
intended the application should be the exact size of the
wound, not spread over the edges, as may be done with oil or
simple dressing, and cover it with a layer of a larger piece of
lint or linen spread with some non-irritating ointment. You
will soon learn for yourselves in the wards to what other
applications this I'ule applies.
Scott's dressing, which is a harder substance to spread
than zinc ointment, should always be kept by the nurse
spread on lint and cut into strips ready for use. It is usually
ordered to be applied to joints, i.e., strips of the dressing-
wound over the joint and then covered with strips of strapping.
Water dressings and some lotions (not evaporating) should
be applied on a piece of lint folded double and covered with
a piece of gutta percha tissue or oiled silk, which should be
cut a little larger than the dressing so as to completely
cover it.
In most hospitals, and this amongst the number, lint is
68 LECTURES ON NURSING. [Lect. III.
used with the plain side towards the patient, and ointments
are spread upon that side. In some books, however, you will
find directions to the contrary, so if you are told to use it in
that way, you need not look upon it as an unheard-of thing.
Your best plan is always to follow the custom of the hospital
in which you are working ; both ways are right, inasmuch as
they have been approved by good authorities who happened
to differ on the subject.
Carbolic oil or oiled lint, as it is generally called in the
wards, should be wrung out very dry and kept in stock
ready for use. When these dressings are wanted they should
always be cut ready for the purpose and put neatly in the
dressing trays, so that they can be readily handed to the
surgeon, and that they may not soil the bedclothes or any
place on which they may be put.
I believe that this is all I have to say to you in connection
with these details.
( 69 )
LECTURE IV.
Now we come to the consideration of cold and heat as I'emedial
agents, their respective propex'ties as sack, and then their
varied foi'ms of application. Cold and heat are relative
terms, and are used in a comparative sense. Temperature is
a state of matter, a condition in which matter is ; not matter
itself. Our original ideas of cold and heat are influenced by
the temperature of our bodies. If a substance is of lower
temperature than ourselves, we call it cool or cold, according
to the degree of difference which exists, and in the same way
we call any substance of a higher temperature than ourselves
warai or hot. A cold substance is warm compared to one
cooler than itself, and a hot substance is cool compared to
one hotter than itself. That is what I mean by saying that
cold and heat are relative terms. For instance, ice is water,
i.e., matter in a state of cold called freezing ; steam is water,
i.e., matter in a state of evaporation. This single illustration
will serve to show you what I mean by temperature being
a state of matter.
Living things produce heat ; or, to put it more forcibly, the
production of heat is a property of all living matter. The
animal heat of our bodies is of the same nature, and caused
in the same way as heat in a fire, that is, by the union of
oxygen with other substances. But I do not propose to enter
into the physiological aspects of the question, nor to say more
about temperature to-night. We will confine ourselves to the
70 LECTURES ON NURSING. [Lect. IV.
properties of heat and cold, as remedial agents, and the
objects for which they are thus employed. Heat and cold
act by modifying the supply of blood to the surface, i.e., by
diminishing it, which is the effect produced by cold ; by in-
creasing it, which is the effect produced by heat. With this
alteration in the quantity of blood goes also an alteration of
sensibility, i.e., diminished sensibility, as produced by cold up
to complete loss of sensation ; increased sensibility, as pro-
duced by heat up to scalding, with all the varied degrees of
sensibility between these two extremes, such as the sensitive-
ness of a surface after the application of a poultice, or the
coolness of a part to which an evaporating lotion has been
applied.
The main uses of these natural agents, then, are : (1) to
modify the amount of blood to the surface; (2) to reduce
temperature ; (3) to increase temperature.
They act as cold producers by direct abstraction of heat,
by conduction, and by evaporation, thus producing a fall of
temperature. I will explain more fully what we mean by
these terms by-and-by.
They act as heat producers — (1) directly by the applica-
tion of a hot substance ; (2) indirectly by the diminution of
evaporation, and so by preventing the fall of temperature.
Now, as a remedial agent cold is employed as a solid, as in
the form of ice bags or Leiter's tubes, and as a liquid, as in
the form of water and cooling lotions.
It is used for at least six distinct objects. (1) As a stimulant
■ — in the way of dashing cold water over people in various
methods. It is thus employed in cases of alcoholic poisoning,
opium poisoning, or in recovering patients from the effects of
chloroform, fainting, and so on. (2) It is used as a tonic —
when employed with a view to producing reaction, as in the
ordinary cold bath. (3) As an abstractor of heat — to reduce
temperature, as in cold packs, evaporating lotions, and that
Leot. IV.] LECTURES ON NURSING. 71
class of remedies. (4) As an ansesthetic — either for the pur-
pose of soothing pain or to produce complete loss of sensation.
(6) As a styptic — to arrest hemorrhage internally or ex-
ternally. (6) To cause contraction of parts, as in cases of
hernia, for instance.
You see that the effects of cold on the human body are
various, according to the way in which it is applied. Cold
M'ater is frequently employed to abstract heat from the whole
surface of the body, or from some particular part of it, or to
induce general or local excitement or shock. It is also
employed to reduce fever and allay inflammation. On ex^
posure to cold, increased oxidation of the tissues takes place,
as is demonstrated by the greatly increased quantities of
carbonic acid thrown off by the lungs. However, until you
know more physiology, it is not needful to enter fully into
these questions. You will not have to prescribe cold in any
form, only to apply it in such a manner as comes within the
province of a nurse's duties ; but I want you to understand
the properties of cold as a distinct form of treatment, that
you may carry out such treatment intelligently, and under-
stand more or less what is aimed at when it is prescribed.
A speedy immersion of the whole or any part of the body in
cold water will first give a sensation of shock and chill, local
or general, as the case may be, which is almost instantaneously
followed by a glowing exhilarating sensation. The next stage
after this is " depression." The cold bath is considered
bracing and very conducive to health when reaction follows.
But the ordinary cold bath, which is so useful as a means of
preserving health, is seldom ordered for hospital patients, and,
except to recommend its use strongly to yourselves, I need not
say much about it. The temperature varies from 70° to
50° Fahrenheit — below 60° it is very cold. A cold hip bath
is not' infrequently ordered in conjunction with a hot foot-
bath, as feeble circulation in the extremities, if thus dealt
72 LECTURES ON NURSING. CLect. IV.
with, need not interfere with the satisfactory application
of cold to other parts. Sometimes the invigorating effects of
a cold bath are increased by the addition of sea-salt to the
water.
When a cold bath is ordered, the patient should not
remain in the water after the reaction sets in, for fear of
the depression which may supervene if the bath is too
prolonged. From three to five minutes is long enough for a
patient to remain in a cold bath, when no special orders are
given.
Ice baths for the purpose of reducing the temperature
of the body are nearly always given under medical super-
vision, and in any case you would only assist in giving them
at first under the immediate direction of those more ex-
perienced than yourselves. In some hospitals ice batlis are
much used for typhoid and other high- temperature diseases.
The utmost care and discrimination is needed. Brandy is
frequently administered to the patient whilst in the bath,
and at any rate it must always be close at hand, with a
measiire-glass, spoon, and some water or milk, in case of its
being suddenly called for.
If no special bath-gown is kept for the purpose, the
patient, after having the night dress removed, should be
wrapped in a sheet, and, as that will cling closely to the body
when wet, it is well to leave one arm uncovered, that the
person who is superintending may have no difficulty in
getting at the pulse, which he or she may probably wish to
feel all or most of the time.
Hot bottles, and often hot blankets, are sometimes asked
k for immediately after the bath, to counteract any symptoms
' of collapse that may ensue.
This is one of the many occasions when it is necessary for
a nurse to exercise her common sense and powers of observa-
tion, to see at once what is needed, and to do what she is told
Lect. IV.] LECTURES ON NURSING. 73
>vith qniet promptitude. A fussy, bustling, noisy person is
intolerable at such a time, and the same may be said of a
slow, unobservant woman, who cannot see what is wanted,
nor do what she is told with the intelligent quickness which
is expected from her.
Ice baths are not resorted to now quite so much as they
were at one time. Cold sponging is employed much more
frequently, and this devolves entirely upon the nurse. You
must remember that it is not necessary to expose the whole
body at the same time, that you must not make the bed
damp and uncomfortable, and that you should do it gently,
quickly, and thoroitgJily.
When ice-cold spojjging is ordered without any special
directions, do not let the process of sponging exceed ten
minutes, for fear of shock to the patient. Tepid sponging
may be made a more soothing process, and need not
be hun'ied over in less than fifteen minutes if it is made
rather pleasant than disturbing to the patient. The best
way of drying patients after sponging is to dab each part as
you finish sponging it with a soft towel. You must en-
deavour to make the whole process as little fatiguing as
possible, as when this treatment is followed it usually involves
frequent repetition.
Cold packing is useful in fevers and acute inflammatory
diseases. The patient's clothes must be removed, and the
whole body enveloped in a wet sheet ; mackintoshes and
blankets must be placed under and over the patient, and
be closely tucked in. The pack should last from thirty to
fifty minutes ; longer, if necessary. This treatment is said
to develop the rash, to greatly reduce the fever, to quiet the
pulse, to render the skin moist and comfortable, and to abate
the restlessness and wandering. It usually induces sleep.
In acute rheumatism, when the intense pain forbids the
patient io be moved, you should pack the front of the body,
74 LECTURES ON NURSING. [Lect. IY.
and put a separate wet compress on each joint, changing the
compress frequently. A compress consists of several folds of
linen, with a piece of dry linen over it. For sore throats a
cold compress is more effectual if it is covered up with oiled
silk or gutta percha tissue. A wet compress placed over the
eyes often induces sleep when other remedies fail. It is a
simple remedy, which can nearly always be tried with safety.
Nurses must recognize the fact that if cold lotions and ap-
plications are ordered, they are intended to he Icept cold, and
must attend to them accordingly. Drip-pots, appliances that
are familiar to any of you who have ever been in the accident
wards, are an excellent means of keeping up a steady supply
of cold lotion. They are simple to arrange, merely consisting
of a small porringer, or basin secured by strapping to some
convenient point over the part for which they are required ;
strips of lint or flannel, with one end dipped in the fluid
contained in the pot, and the other hanging over the side,
will secure a steady drip of the liquid as long as there is any
left in the vessel. The nurse must make a careful ari^ange-
ment of the bed with mackintosh, and in some cases an
earthenware receiver of some kind to receive the lotion as it
trickles down ; but^ having done this, she has only to recollect
that the drip-pot will require to be kept constantly full. It
is certainly the method of keeping up a constantly cold and
moist application which gives least trouble to the nurse. I
cannot say that they add to the neat appearance of the
ward ; but this is no argument against their use, though it is
a strong reason for nurses to exercise such ingenuity as they
may be foi'tunate enough to possess in making them look as
little untidy as possible.
If you are applying cold rags dipped in water or spirit
lotion to the head or any inflamed surface where there is no
wound, use two rags or handkerchiefs, that one may have
time to cool perfectly in the lotion, ready to replace the warm
Lect. IV.] LECTURES ON NURSING. 75
one. If yoii want to keep a cold, moist application over a
wound, do not wring out a soiled v&g or piece of lint in the
lotion. It is dirty both for yourself and the patient. Moisten
the piece of lint by dabbing it freely and gently with a
clean piece dipped in the lotion and taken out dripping,
until it is desirable to remove the piece next the wound, and
replace it by a fresh one altogether. Moist cold applications
must not be dry and lukewarm — that is not a trustworthy
candying out of oi'ders. I will not suppose that any of you
would content youi'selves with just having it right for the
doctor, and deliberately neglecting it at other times, though I
am sorry to say that I have known nurses who consider that
sufficient. I want to impress upon you that you must not
content yourselves with meaning to keep it right, " unless
you forget." Nurses, if they are to be depended upon, mjist
learn to remember, and carefulness in these details is not
only important for yourselves, but absolutely essential to the
welfare of your patients.
Ice is immensely iised in medical, surgical, and obstetric
cases, both externally and internally, as a convenient form of
applying intense cold. It must be remembered that exti'eme
cold applied to one part without intermission produces loss of
sensation, and so acts as an anassthetic ; if too prolonged, the
part will die, and become gangrenous. The benumbed con-
dition is preceded by a sensation of pain, which must be
avoided by care in the application when ice is intended to act
as a refrigerator, and not as an antesthetic. Ice is employed
to abstract heat, to allay imflammation, to check bleeding,
to produce contraction, and to destroy sensation. Externally,
it is usually oi^ered in the form of bags, or in the form of
Leiter's tubes, which are now frequently employed for all
parts of the body.
The use of ice bags as an effectual means of applying cold-
treatment locally needs rather more care and attention than
70 LECTURES ON NURSING. [Lkct. IV.
some nurses ai^e inclined to think. If they ar'e allowed to
remain on when all the ice has melted, it is not only that
they cease to be of service, but that they do positive harm,
by inducing the reaction which, you all know, follows the
removal of any cold application.
If 3^ou have not fresh ice ready, as it should be, it is
better to remove the bag than to leave the bag of hot Avater
applied to the part [ior which ice has been ordered ; for
dii'ectly the last piece of ice has melted, the temperature of
the ice water will rise rapidly to that of the part with which
it is in contact. Wet rags renewed frequently may be em-
ployed in the interval, if it is very important to keep up
the treatment.
Ice bags should not be much more than half filled, and
must be so arranged that the entire weight does not rest on
the patient, though the bag does. This is easily accom-
plished, when the ice bags are needed for injured limbs,
by tying the bags to the cradles placed over them, and, if
they are properly arranged, this keeps them in excellent
position. It is rather more difficult to keep them nicely
applied to the head, partly on account of the frequent rest-
lessness of the patient in cases where this remedy is pre-
scribed, and partly because there is not usually anything able
to bear the weight to which the ice bag can be attached,
immediately over the patient's head. The little cords with
the means of raising or lowering the bag, or moving it from
side to side, which are used in the wards, serve admirably for
the purpose in this hospital, where we have rods for the
curtains ; and when you have beds without, you must exercise
your ingenuity and adapt it to the requirements of your patient
as best you can.
Ice bags must not be placed next the skin, as the applica-
tion of intense cold is painful, and a thin covering between
the bag and the patient makes a vast difEei-ence in the
Lect. IV.J lectures ON NURSING. 77
comfort, and sometimes in the possibility of bearing it. It
serves the twofold purpose of preventing fi*ost-bite and of
absorbing the moisture condensed on the surface of the ice
bag. It is not necessary to put the usual piece of lint between
when applying ice bags to the head, unless it is shaved or
bald, as the thickness of the hair answers the same purpose.
In the well-known " Handbook for Hospital Sisters," by Miss
Florence Lees, she tells us that "Dr. Stokes considers that
the best way of applying ice to the head is to place a smooth
piece of ice, two or three inches long and one and a half
broad, in a cap of soft sponge, and pass it round and round
over the head. The sponge absorbs the water, and the pain
of the cold is avoided. When the sponge is saturated, it is
to be squeezed, and the ice replaced." This is not very
applicable to the majority of cases in a hospital, but I consider
it a valuable hint for private nurses, and it may sometimes
be serviceable with bad cases that have special nurses, whose
sole duty it is to attend to them. Ice bags for the head or
limbs are convenient in the form of an ordinary bladder, or
made of India rubber somewhat of that shape.
Gmall ice bags for the throat, eyes, forehead, etc., are best
made for each case by the nurse, of gutta percha tissue
fastened into the required shape with chloroform, which will
dissolve and stick the edges of the bag together quite
securely. A little practice is necessary to do this neatly, but
no special skill, for it is perfectly simple. A nurse should
endeavour to adapt the shape of these to each case. For
instance, those that are wanted to pass under the chin arc
. best rounded out a little, and quite as easily made.
The same bags can be used, for the same patient, two or thi-ee
times if the ice is put in carefully. A double supply of these
bags should be used, so that in removing one the other can
be instantly replaced, and the patient is not disturbed twice.
This is a gi-eater consideration with small ice bags, inasmuch
f 8 LECTURES ON NURSING. [Lect. IV.
as the ice melts quickly, and they have to be frequently
renewed. In changing these little bags when the ice has
dissolved, cut off the extreme end, and, after emptying out
the water, leave it to get q^uite cold before refilling it with ice.
The ice must, of course, be broken up into small pieces, to
make it as little uncomfortable ^.s possible for the patient.
If ice bags cause persistent pain, always report it.
Many of you are already familiar with Leiter's tubes, an
invention for maintaining a steady supply of cold to almost
any part of the body for which it may be required. A pail
of iced water is placed above, or at any rate higher up than
the patient, from which a tube supplies the water to the
pliable tubes placed on the patient. When the iced water has
circulated through these it is conveyed by another tube to a
vessel placed ready to receive it. A nurse should see from
time to time that the water is flowing through properly, as
the tube is a little apt to get stopped up and become in-
effectual, until a vigorous "blow" up the tube puts it all
right again. A piece of lint must be placed between the
patient and the tubes for the same reason that it is employed
in the application of ice bags, and the pail containing the
iced water must be neatly covered round with flannel or some
other material to absorb the moisture which rapidly con-
denses on the outside of the pail and will otherwise drop on
the bed or the patient.
Ice is best broken by any instrument that has a very fine
point. For dividing small pieces noiselessly and quickly,
there is nothing better nor more convenient than a strong
needle. If you wish to break it without waking a patient,
you should place the piece to be divided in your hand, on
a small handkerchief or cloth, and it will scarcely make the
faintest sound.
Ice keeps best in large pieces, so never break it up into
small ones until required for use. When you have no
Lect. IV.] LECTURES ON NURSING. 70
refrigerator, ice should be kept wrapped up iu a dark place,
and put in such a manner that the water may diip away from
it a.s it dissolves, and none of the remaining ice stands iu the
water.
When ice is wanted for a patient to suck, it should not
be put on the locker in a saucer, so that as it dissolves the
remainder is kept in the water, and consequently melts faster
than it otherwise would do. The best and readiest hospital
arrangement for the purpose is to take a jam pot, and tie a
little piece of new flannel or lint over the top, depressing it
in the centre to make a convenient place for putting the ice
in. An end of a rib bandage is often wide enough for the
purpose, and it looks well if tied on with a morsel of scarlet
or blue wool, which is genei'ally to be had at a moment's
notice in the wards. It looks all the better in the wards of
those nurses who take the trouble to keep pieces in readiness,
with the comers of the flannel rounded off and worked over
with a little of the coloured wool, but of course this is an
ornament, and not a necessity. A plain piece of flannel tied
on with a bit of thread is all that is absolutely necessary for
the purpose. The jar should stand in a saucer, so that any
overflow of water may go into that, and not wet the top of the
locker; the greater part of it will drop into the jar while
the ice remains on the top of the flannel.
Ice is used internally to allay thirst, to check bleeding
fi-om the mouth, throat, stomach, or lungs, and to allay
nausea and sickness. Constant sucking of ice is most efficacious
for acute inflammation of tonsils ; also for the sore throat of
scarlet fever. In some cases of diphtheria it is well for the
patient to continue sucking it, if possible, till the disease has
fairly declined. It may be given to most patients, and must
be given to some. Children generally dislike it, because it
makes their teeth ache. Some care is necessary in giving it
to unconscious or delirious patients, lest it slip into the
^0 Lectures on nuesiNg. [lect. iv.
trachea, and bring on a fit of choking. It may be given for
the sickness which so often follows the administration of
chloroform and ether, when the patient is sufficiently re-
covered. Ice taken internally has a tendency to cause con-
stipation, and consequently to check diarrhoea.
Two parts of finely powdered ice and one part of common
salt, forms an anaesthetic sufficient to freeze tissues. It will
cause vesication if applied too long, but will not do so under
six minutes. The ether spray is usually preferred now.
Ice bags are sometimes applied to the head in delirium
tremens, and for the convulsions of children. Spinal ice bags
are said to be invaluable for convulsions, and many other
purposes. The mode in which they act, and the various
ways of applying them for diffei'ent objects, are much extolled
by Dr. Chapman. Amongst other results, he states that the
application of ice to the spine will speedily make cold feet
comfortably warm. I mention the fact, thinking it may
interest you to notice it next time you have an opportunity,
though it would be out of place to enter into the physiological
explanation of it which he gives.
This, I think, is all I have to bring to your notice in
reference to a nurse's duties in applying cold as a remedial
agent both general and local. There is rather more detail to
speak of in connection with the local applications of heat ;
but I think I shall still have time to-night to speak of its
uses as a remedial agent, and of the manner in which it can
be employed as a means of general treatment.
All bodies have a certain heat. The terms " heat " and
" cold " are only relative, as I have previously told you. All sub-
stances which are hotter than their neighbouring bodies, tend
to give up their heat until equalization is reached. Bodies lose
heat by conduction, by radiation, and some by evaporation.
I need not take up your time by endeavouring to give you a
full explanation of these terms, but I think it is essential that
Lect. IV.] LECTURES ON NURSING. 81
you should understand what is meant by the term " evapoi^a-
tion." " Evapoi-ation is the passage of a fluid into a gaseous
state." You know that fluids are volatile in various degrees.
If you place a saucer of eau de Cologne and a saucer of water
in a room, you are most of you aware that the saucer which
contained the eau de Cologne would be dry first ; i.e., the
evaporation of the spirit will be much more rapid than that
of the water. Heat especially increases evaporation. If you
placed a lighted spirit lamp under either the saucer of eau
de Cologne or of the water, the evaporation would be much
quicker in both instances. During the process of evaporation
— i.e., of the passage of a fluid into a gas or vapour — heat is
used up. This heat must come from somewhere, and it comes
from what is in the immediate neighbourhood, i.e., from the
bodies nearest it.
Of course, for a body to lose heat by evaporation, it must
contain fluid, evaporation being defined as the passage of a
fluid into a gaseous state. Such bodies as do not contain fluid
can only lose heat by conduction and radiation. Oar bodies
do contain fluid ; therefore we lose heat, to some extent, by
conduction and by radiation, but evaporation is our chief
means of loss.
Now, our bodies produce heat and lose heat. I must not
linger to describe to you the manner in which we produce
heat, but I want you to grasp the fact that our mean tem-
perature is the balance between the production of heat in
us and the loss of heat from us ; and eithei' the pi-oduction
or the loss may be increased or diminished, and so the
temperature rises or falls. To be more explicit, if we produce
heat in excess, and do not lose heat in the same proportion,
our tempei-ature rises ; if we do not produce more than the
normal amount of heat, but lose less than the normal amount
of heat, our temperature rises. Speaking generally, the in-
crease of temperatiire is usually due to our not losing the
G
82 LECTURES ON NURSING. [Lect. IV.
normal amount by evaporation. This brings us to the more
practical part of our subject. As heat materially assists in
producing rapid evaporation, the application of it is frequently
emploj^ed for this purpose, and the temperature is thus
lowered.
Heat can be either dry or moist. We can bear the
application of dry heat at a much higher temperature than
that of moist heat. An excess of dry heat turns ; an excess
of moist heat scalds. The temperature of dry heat which
can comfortably be tolerated, in a Turkish bath, for instance,
would scald if it were moist heat. The atmosphere can only
absorb a certain amount of moistui-e. If the atmosphere has
absorbed its full amount evaporation cannot take place, and
one chief means of losing heat is prevented.
Heat, both moist and dry, can be subdivided in the same
way as we have treated rest and cold — in the general appli-
cation of it to the vfhole body, and the partial application
of it to relieve or cure locally. To-night we will consider the
general application of heat, both dry and moist. The effect
of dry heat, applied generally, is to produce perspiration, and
that is the object for which it is ordered, as a hot air bath,
for instance. The object and effect of diy heat when applied
partially is to impart heat to the part with which it is placed
in contact, as in a hot bottle or brick. General moist heat is
prescribed with a view to its sedative effect, and this is the
remedial property for which it is ordered in conditions both of
nervous and muscular excitement, as after great fatigue, etc.
Now we will proceed to the details of the application of
general heat both dry and moist. Hot packing is sometimes
employed in cases of dropsy, ursemia, etc. The patient's body
linen should be removed, and a mackintosh placed over the
mattress, covered with a warm dry blanket. Hot packs are
ordered at a varying temperature, usually 100° Fahrenheit
when no special directions ai'e given, but it must be remem-
Lect. IV.] LECTURES ON NURSING. 83
bered that if the patient is to be enveloped in a wet sheet or
blanket at the temperature prescribed, the water in which it
is steeped must be at the very least 10° higher than that, or
the orders will not be accurately carried out. The higher
the temperature, up to 100° at any rate, the more comfortable
the application is likely to prove to the patient. When the
choice rests with you, a wet sheet is much more adapted to
the purpose than a wet blanket, the latter being very heavy
and cumbei'some to arrange, and if the patient is quickly
covered up with mackintosh and blankets the heat is
effectually retained. Patients are usually kept in a hot pack
for about an hour, but they may remain longer if comfortable;
Occasionally it has a soothing effect, and induces sleep. In
taking a patient out of a hot pack it is best to remove the
mackintoshes and everything that has become saturated with
moisture, and leave him rolled up for a short time in a warm
dry blanket. This has a tendency to increase the action of
the skin, and lessens the risk of chill. Finally the patient
should be comfortably dried with warm towels, great care
being taken for some time after the pack that he is not
exposed to any draughts, and that all chances of cold, such
as an open window during the process of being put comfort-
able and having the bed made be observantly and scrupulously
guarded against.
Hot air baths are frequently ordered for dropsy cases. A
long cradle, or sometimes more than one, if you have not one
of sufficient length, must be placed in the bed, and the hot
air apparatus fitted in at or near the foot. The sheets and
the patient's night dress must be removed, and it is well to
put a mackintosh beneath the blanket on which the patient
is to lie to ensure the bed or mattress being kept quite dry
and clean. The blanket placed over the cradle must be cai:e-
fuUy tucked under the patient's chin and round the edges
of the bed, the blanket covering the patient during the
84 LECTURES ON NURSING. [Lect. IV.
arrangement of the bed being now removed and placed over,
not under, the ci-adle, the whole being finally covered with
a mackintosh, and arranged in such a way as to prevent the
escape of the hot air.
Miss Florence Lees gives the usual temperature as varying
from 100° to 160° Fahr., and the usual duration of the hot air
or lamp bath as twenty minutes, but both time and tempera-
ture vary according to the cases and the views of the
physicians who prescribe them, and you mast, of course,
endeavour to carry out the orders given in each case.
After the lamp has been removed, the patient should be
allowed to perspire freely and to cool a little before being
thoroughly dried with a warm towel. A warm night dress
should then be put on, and the moist blankets replaced with
dry, warm bedding.
A warm bath or a vapour bath prior to a hot air bath
increases the effect. Sponging with warm water whilst in
the bath is sometimes ordered with a view to increasing the
action of the skin. Baths both for medical and cleansing
purposes, depend for their successful application upon the
efficiency of the nurse. Ordinary cleansing baths are usually
given at a temperature of not more than 80° to 92° Fahr.
Of course a patient must not be allowed to have a bath until
you have asked the sister, but when there is no reason to the
contrary, a bath is a quicker and more effectual method of
making a patient clean and comfortable than the slower
process of washing them all ovei', as you are frequently
obliged to do.
Wever leave a patient alone in a bath if you are responsible
for it. No doubt you have all heard of accidents at children's
and other hospitals occurring from neglect of this rule. In
warm baths some patients with weak hearts or in a weak
state of health are apt to faint, and some are quickly
depressed in cold baths, so that, however sure you may feel
Lect. IV.] LECTUKES ON NURSING. 85
that no contingency of the sort is likely to arise, you have
no right to run the risk.
The temperature of baths varies somewhat as follows :
tepid baths, 86° to 92° Fahr. ; warm baths, 92° to 98°
Fahr. ; hot baths, 98° to 106° Fahr.; 112° Fahr. would
be very hot. A hot bath i*anges from the temperature of
the body upwards ; vapour baths, 122° to 144° Fahr. The
scale of temperature varies slightly at different places, but
I believe this is about the usual average. I give you these
particulars for general guidance when yon do not receive
precise directions, but whenever you are in doubt about what
is best for any case in the wards always ask the sister.
Let me strongly recommend you to get into the habit of
using the bath thermometer on all occasions. Expeiience
will give you a tolerably correct idea of about what tempera-
ture the water is, but not unless you have employed the
thermometer regularly, and thus learnt exactly what water
feels like at the varying temperatures recorded. In using
the thermometer remember that it must be thoroughly
immersed in the water for a few seconds before reading it,
and not a little water scooped up just to cover the bulb, as
I have known some nurses consider sufficient, or of course
it will not give the true temperatui-e of the full quantity
of water. It is always best for a nurse to be strictly
accurate over every detail in which it is in her power to be
.so, instead of having to report vaguely that it is " about so
and so."
When a patient is ordered a bath for medicinal purposes,
at a certain temperature, you are intended to keep the bath
as neai-ly as possible at that tempei-ature all the time the
patient is using it. If you content yourself with giving it to
the patient at the required temperature to begin with, it is
evident that you will not be carrying out your orders
efficiently. To do this you must have a supply of hot water
86 LECTURES ON NURSING. [Lect. IV.
at hand to add from time to time, and take care to pour it
in gently and slowly hy the side of the hath, so that the patient
may not fear being scalded.
See that you have everything quite ready before disturb-
ing the patient, so that he or she may not have the fatigue
of waiting about, and the risk of getting a chill. In this as
in other things of the sort, a nurse who has a head and uses
it will save both her patient and herself a great deal of time
and trouble.
As a hot bath induces perspiration patients should have
a blanket wrapped round them, and not be allowed to stay in
a draught or near an open window, neither should they bo
allowed to walk about the ward on any pretext whatever
until the immediate effect of the bath upon the skin has
passed off. Unless specially ordered, a patient should not
remain in a hot bath longer than eight or ten minutes.
Hip baths are useful when it is considered desirable to
immerse that part of the body only. When it is a hot hip
bath ordered for medicinal purposes, an even temperature
should be maintained, and a blanket thrown over the patient.
People who have a feeble circulation are sometimes ordered
to take a cold hip bath and a warm foot bath at the same
time, as I said just now.
Arm and leg baths ai'e much used now for surgical cases.
You must take care to place them and the patients in such
a position that they may be as little fatigued and uncomfort-
able as possible. It is a tiring remedy for patients, owing to
the length of time they are sometimes required to keep the
limb immersed. In this case also the nurse must maintain
the temperature ordered.
Mercurial vapour baths are contrived in various ways,
and the best methods must be learnt by practical observation.
Mustard baths are frequently ordered. The mustard
must be put in a bag or tied up in a piece of flannel or linen
Lect. IV.] LECTURES ON NURSING. 87
after the fashion of a blue bag. The quantity of mustard
varies according to circumstances.
Sulphur and tar baths are sometimes ordered, but for
these you will receive special directions in each case.
The application of moist heat mitigates or removes the
pain of colic ; it relieves spasms ; it takes down inflammation.
Immei*sion in very hot water is said to relieve sprains. Hot
water applied to the feet and legs sometimes removes head-
ache. Sponging Avith very hot water will occasionally
relieve severe headache when cold treatment altogether fails.
The prolonged application of hot baths or any form of heat
is said to bo weakening.
In our next lecture we will consider this subject further,
and moi-e particularly with i-eference to the local applications
of heat as applied in the form of poultices, fomentations, and
other remedies of a similar kind.
88 LECTURES ON NURSING. tLECT. V.
LECTURE V.
We have now to consider the details of the various forms in
which heat can be applied locally as a remedial agent. We
completed the subject of the general application of heat, both
dry and moist, at our last lecture, and the partial application
of heat can be conveniently subdivided under the same
headings.
I should remind you, to begin with, that the effect
of dry heat applied generally is to produce perspiration, and
that is the object for which it is ordered, as, for example, a
hot air bath.
The object of dry heat, when applied partially, is to
impart heat to that portion of the body with which it
is placed in contact. The partial application of moist heat
is ordered with a view of softening the skin, and thus
relieving tension and pain. The early application of moist
heat has a tendency to cut short inflammation, as you may
sometimes have noticed when a poultice has been applied to
a bad finger directly it becomes painful. The effect of a
poultice when applied later is to enconrage discharge, and so
to favour healing.
Dry heat, as I told you last time, can be tolerated at a
much higher temperature than moist. Dry heat for local
application is usually ordered in the form of hot bottles,
bricks, bags filled with hot salt, bran, camomile leaves,
or other herbs, to impart heat to the place in question.
Lect. v.] lectures on NURSING. 89
and to relieve pain. The latter are not often employed in
hospital pi-actice, bnt the application of hot water bottles or
tins is very familiar to you, as they are in daily use both in
medical and sui'gical wards.
Of all the times when the hot Avater tins should be
refilled as a matter of daily routine, the early morning
is, perhaps, the most important, and I am afraid that this
is the time when many nurses and probationers are careless
about attending to them. The vital powers of the patients
are at their lowest, and nearly all your bad cases are worse
than in the evening, when they are more inclined to be warm
and comfortable. It is bad management for a nurse to think
that the fact of her being busy excuses or explains why her
patients should be cold.
When you have a large ward full of patients on your
hands, it is not to be expected that you can stay to fill every
hot bottle, when perhaps you have a dozen beds to make in a
very short space of time ; indeed, it would be bad manage-
ment to do so. The right plan is for night nurses and
probationers to refill hot water bottles in the very early
morning ; then, when day nurses and probationers come on
duty and make the beds, the bottle serves as a sensible foot-
stool for such patients as may only just be able to move from
their beds while they are made, and there will be no need for
the foot wanners to be attended to again until the wards are
all straight, and there is leisure to see after them. Moreover,
the patients will have had the benefit of them exactly when
they were most needed, instead of having to wait until " nurse
has time."
Whilst I am speaking of hot water bottles, there arc
one or two points in connection with them that I may
as well mention to you. Always take care that a sheet,
blanket, or some covering is placed between the patient and
the surface of the hot water bottle or tin. The contact with
90 LECTURES ON NURSING. [Lect. V.
it makes the skia tender, and is often startling and uncom-
fortable to the patient if he is awake, and will rouse him
suddenly if he happens to be asleep. Do not be satisfied
with yourselves until you can take the hot watei* bottle or
tin out of and put it in the bed without waking* your
patient.
I think you cannot be told too soon of the special risk
there is of raising scalds and blisters on paralyzed and
dropsy cases, especially the former, by bottles that would not
be hot enough to affect other cases in the same way. I hope
you will remember this, because you may any day be told to
place plenty of hot water bottles in the bed Avith these
patients, and it would be distressing for you to find that
through ignorance of this peculiarity you had inadvertently
hurt the patient in this way. He might not be conscious of
the pain, or not able to call your attention to it; but any
wounds in these cases are very slow to heal, and it is necessary
to take extreme care to avoid them,
I do not think there are any special points to which I
need call your attention in connection with the other methods
in which dry heat is sometimes applied.
Moist heat is usually prescribed locally in the form of
fomentations and poultices of various kinds. Fomentations
are preferable to poultices on the ground that they are
cleaner of application, easier made, and easier borne by the
patient, but the di-awback is that they do not retain the heat
nearly so long. The best material to use for fomentation is
coarse flannel or soft old blankets.
A wringer, made like a small roller towel, should be
placed over a bowl, with the two sticks ready in each side
of it, and the flannel placed ready for quite boiling water
to be poured on it. It must then be wrung out as dry
as it is possible to make it, by turning the sticks rapidly
in opposite directions and keeping them as far apart as the
LixT. v.] LECTUEES ON NURSIKQ. 91
size of the wringer will permit. Then untwist and slip out
the sticks as quickly as possible, give the fomentation flannel
a good shake, and place it lightly on the patient, covering it
up with mackintosh or other waterproof material, which is
placed over the fomentation with the twofold object of
retaining the heat and keeping the patient dry. Nothing
is so excellent for this purpose as spongio-piline. The
soft side absorbs the moisture from the flannel, and the
waterproof side keeps the damp from coming through. To
render it quite effectual, the edges should be bevelled inwards,
so that the waterproof portion completely covers the whole.
This should be placed before the fire to keep it warm, ready
for use, while the fomentation is being prepared. Fomen-
tations to be effectual should be changed every ten minutes
or quarter of an hour, and I am sure any one who has
ever experienced the relief they give in severe pain will
be of this opinion. Another flannel should always be wrung
out ready to replace the cool one, that the patient may not
be kept waiting while the same flannel is made hot. The
cool flannel and the wringer should be hung up to diy
in readiness for the next application. This appears a trifling
detail to which to call your attention, but experience shows
that in some cases it is essential to mention it. Fomentations
are uncomfortable, and of no service if allowed to remain on
too long without changing.
Sometimes fomentation flannels are ordered to be wrung
out of a decoction of poppy heads, or other herbs, instead of
boiling water. In this case they do not require changing
quite so frequently. To make this poppy water, Miss Florence
Lees give the following receipt : Take four ounces of dried
poppy heads, break them to pieces, and empty out the seeds ;
then boil the shells in three pints of water for a quarter of an
hour ; strain and keep the water for use.
Mallow water and camomile flower water are made in the
92 LECTURES ON NURSING. [Lect. V.
same way, and frequently camomile blossoms are boiled with
the poppy heads. Sometimes a few drops of laudanum or
tincture of belladonna, or ether, or chloroform, are ordered to
be sprinkled upon the fomentation flannel after it is wrung
out, for the purpose of relieving pain. Turpentine is occa-
sionally ordered to be sprinkled on the flannel. This is
usually spoketi of as a turpentine stoup.
Miss Wood recommends from thirty to sixty drops of
turpentine ; Miss Lees from one to two tablespoonf uls, which
I consider excessive, unless the turpentine is mixed with the
boiling water before the flannel is wrung out ; but, as the
turpentine floats on the top of the water, unless it is used
instantly, this is not very generally done, nor a desirable
method. Unless you have distinct orders as to quantity, you
must use your own judgment, and remember turpentine is a
powerful irritant, and that it is necessary for you to be both
careful in the application and watchful in the use of it,
especially with old people and children. It will break the
skin very quickly if you are careless about it, and we have
already agreed that the aim of skilful nursing is to carry out
orders efficiently, without causing one moment's unnecessary
pain or discomfort. Spongio-piline or a double layer of lint
will foi-m a good substitute for flannel when the latter cannot
be had, but coarse white flannel is generally considered the
best and most comfortable material for the purpose when it
can be obtained, covered with spongio-piline if possible
instead of mackintosh.
When you are briefly told to apply a poultice, and no
further particulars are given, you will take it for granted
that it is to be made of linseed-meal, and in hospitals this is
generally made on tow instead of linen.
To make a linseed-meal poultice properly, you require a
poultice bowl, a basin, a poultice spatula, a poultice board,
and a little olive oil, in addition, of course, to boiling water,
Lect. v.] lectures on NURSING. 93
linseed-meal, and the tow or linen. Pour a little boiling
"water into the poultice bowl, and place the blade of the
spatula in it, while you prepare the tow. A verbal description
of how to prepare the tow will scarcely give you a very clear
idea of it, but any day you can have a practical illustration of
this in the wards, the object, of course, being to make it
smooth and of an even thickness. Then pour the water,
which has been warming the poultice bowl ready for your
use, into the basin, and pour boiling water sufficient to make
the size poultice you require into the warmed poultice bowl.
Only observation and experience can teach you to judge of
the quantity, but this you will soon learn. Then take linseed-
meal in your left hand, and sprinkle it freely into the water,
rapidly stirring with the right hand in one direction all the
while. It should be made of the consistency of porridge, just
thick enough to be cleanly cut with the spatula. It must
then be i-apidly spread on the tow, and the spatula should be
frequently dipped into the basin of hot water, partly to
prevent the poultice sticking to the spatula, and also to make
it spread smoothly.
Different opinions prevail as to the thickness of a linseed-
meal poultice. Miss Wood says, in her " Handbook of
Nursing," that it should be " about one-eighth to a quarter
of an inch thick," which I consider too thin. Dr. Smith, in
his excellent "Lectures on Nursing," says "half an inch
thick," as the general rule, and that is the advice I recom-
mend you to follow. You must endeavour to avoid the two
extremes of making the poultice too thick and heavy, which
is very objectionable, and of making it too thin, so that it does
not retain the heat.
You must leave a border of tow, or of linen, if you
are making it on that material, all round, which must
be lightly rolled back upon the poultice, and a little olive
oil may be sprinkled and smoothed over it to prevent sticking,
94. LECTURES ON NURSING. [Lect. V,
and to cool the surface. Even without the oil, if the poultice
has been properly made, and the spatula dipped in hot water
passed lightly over it, it should never stick, either to the
patient or to itself when folded together. A nurse will always
know that her poultice falls short of perfection if it adheres
to the skin in the least. For children it is always best to use
a little oil, because the cool surface enables them to bear tho
poultice applied warmer than they will do otherwise.
Poultices should be put on as warm as the patient can
comfortably bear them, unless contrary orders are given ; but
great care must be taken not to scald, and it must also be
remembered that frequent applications to the same place make
it tender, so that it is probable for this reason that the patient
may not be able to bear repeated poultices quite as warm as
the first. Always maJce them as hot as possible, for they cool
rapidly, and a poultice put on cooler than it could comfortably
have been borne is not satisfactory. N"ever put a poultice in
the oven to keep hot ; it only dries and hardens it, rendering
it«quite unfit for use. If it happens that you are obliged to
keep it waiting before using it, place it between two hot
plates over a saucepan or kettle of boiling water, but never
do this when it can be avoided.
Always prepare your patient as much as possible before
making your poultice, but without removing the former
poultice until you have the fresh one there ready to put on.
In surgical cases, where the wound requires washing, that
should be attended to, the poultice removed, and the part
covered with wet lint to keep the air from it while the fresh
poultice is made ; but I am speaking more particularly of
medical poultices now, and not so much of those which come
under the head of dressings.
For instance, in bad chest cases, where perhaps you have
a large jacket poultice made in two parts and bound on with
a rib bandage, take the precaution to unwind the bandage,
Lect. v.] lectures on NURSING. 95
and have that or another one wound ready for use before you
begin to make the poultice, taking cai*e to replace the poultice,
covering one-half before removing the other part, and thus
avoiding the risk of chill. When you have learnt to be very
quick, and your patient is not too exhausted to bear it, it is a
good plan to wipe over the place where the poultice has been
applied very gently and rapidly with a small piece of lint or
cotton wool, because the air coming to the moist surface gives
it an uncomfortable itching sensation; but do not let your
patient and the poultice get cold together while you are
interesting yourself with picking off any little dry bits that
may have adhered to the patient.
For medical cases, where there is no wound, you must put
a piece of thin mackintosh or other waterproof material over
the poultice, because it will keep it moist and warm for a
much longer period, and thus save the patient the fatigue of
having it changed so often. Gutta percha tissue is not a good
material for this purpose, although it is waterproof, because
it shrivels up with the heat and smells objectionable.
Poultices applied in this manner usually require changing
every four hours, and would need to be renewed oftener but
for the covering.
Large poultices keep warm for a much longer period
than small ones, so that in making small poultices you
must be particular that evei'ything you use is thoroughly
warmed, and they will need to be renewed more frequently.
It is a good plan to change large poultices every four
hours, and small poultices every two hours, when no orders
are given. Of course, when orders are given, you have only
to carry them out, whatever they may be.
Poultices applied to wounds must not be covered up with
mackintosh, and all surgical poultices must be very light, and
the size carefully adapted to the requirements of the case. If
they ai-e ordered for the purpose of bringing forward an
96 LECTURES ON NURSING. [Lect. V.
abscess, they should be as warm as the patient can com-
fortably bear them, and frequently renewed.
A few drops of laudanum sprinkled on the surface of the
poultice is often very effectual for soothing pain, but be
especially careful if ever you are ordered to use this for
children, and never exceed the quantity prescribed. It may
be as well to take this opportunity of reminding you that
childi'en are peculiarly susceptible to the influence of this
di'ug, and can never bear its application in any form in
anything approaching to the same proportion as adults.
Sometimes linseed-meal poultices are made with a decoc-
tion of poppy heads or other herbs instead of boiling water,
and that often affords relief in severe pain. Linseed-meal
poultices are always placed next the skin, and should never
have a covering of muslin, nor anything else between.
In applying poultices to paralyzed or dropsy cases the
same warning which I gave you in reference to hot water
bottles must be remembered. I mean the extreme liability of
these cases to become scalded on the application of any hot
substance at a temperature not sufficiently high to produce a
similar I'esult in other conditions of the body.
Charcoal poultices are frequently ordered for a wound
where there is a great deal of foetid discharge. The simplest
method of making them is to mix one part of charcoal with
two parts of linseed-meal, and then make the poultice in the
ordinary way. This is cleaner and more effectual than
sprinkling the charcoal on the surface of the linseed-meal
poultice, as is sometimes done. The same purpose is served
in a much cleaner and nicer way by mixing linseed-meal
with boiling coal-tar lotion instead of water.
Some skill and practice is required to make a good
bread poultice, for it is apt to become either heavy, lumpy,
and sloppy, or dry, hard, and sticky. The best method of
preparing them is fii'st to get ready a sufficient supply of
Leot. v.] lectures on NUESING. 97
bread crumbs, and then stir them into the boiling watei'
exactly in the same way as you would linseed-meal, stirring
and beating it rapidly all the while. Then cover it up with
a plate or saucer, and leave it by the fire, or, better still, over
a kettle of boiling water for about five minutes to give it time
to swell. Then spread it on linen — never on tow — dipping
the spatula into hot water to prevent sticking, and turn up
the outside margin of linen in the usual way. You will
need some olive oil or simple dressing to spread on the
surface — the latter looTcs best, but either will do — because
bread has a great tendency to stick, and it hurts very much
if dry, hard, little pieces have to be picked off the edges of a
wound.
You cannot roll bread poultices up in the same way
that you can linseed-meal, nor fold them up to take to a
patient, or they will break and fall to pieces. They are
applied either hot or cold, according to orders. It will
save time and trouble if you make a sufficient supply at
one time for two or three poultices, as the preparation does
not spoil, unless it is left long enough to turn sour, and it
can easily be warmed afresh over a kettle of boiling water, or
by the addition of a little hot water to the soaked bread.
Bread poultices are placed next the skin.
Mustard and linseed-meal poultices are frequently used.
The difficulty of mixing these ingredients is obviated here
by your having the material prepared from the dispensary.
When you have to prepare this poultice for yourselves,
the best method is to put the mustard first into the boiling
water, and see that it is thoroughly mixed before adding the
linseed-meal in the usual way. By this means you avoid the
risk of the mustard remaining in patches to irritate the
skin.
But in recommending this plan I must be careful to ex-
plain to you that the mustard can only be mixed with boiling
H
98 LECTURES ON NURSING. [Leot. V.
water when the object is to secure a diffused redness over the
whole surface to which the linseed-meal poultice has been
applied, and not when it is desired to produce the maximum
irritating effect for which mustard plasters are prescribed.
A lesser and sufficient irritation is effectually produced in
the manner described, and the discomfort of the mustard
stinging in little patches avoided. The reason why mustard
should not be mixed with boiling water under other cii-cam-
stances was clearly explained to me by an eminent physician
in a kindly criticism on my " Lecture on Home Nursing,"
where I briefly gave the suggestion referred to for making a
mustard and linseed-meal poultice. He said, " The value of
mustard as an external application is due to volatile oil,
which does not pre-exist in the mustard, but is produced by
the action, when moistened, of a body called myrosine on
another body called myronic acid. The myrosine acts like a
ferment on the myronic acid, and produces the oil. Hot
water, and especially boiling water, coagulates the myrosine,
prevents its action on]_the myronic acid, and fails" in producing
the oil, or at any rate diminishes its formation." It is
therefore not difficult to understand why mustard must
never be mixed with boiling water when its maximum effect
is desired.
If these poultices are ordered for a continuance, and
the skin appears likely to break in places, you must cover
these spots with very small pieces of lint or linen, spread
with zinc ointment or simple dressing, before applying the
poultice, and then the patient will not be obliged to dis-
continue remedies which may be deemed necessary for his
case in consequence of the local discomfort.
Mustard-leaves that you procure from a chemist are nearly
always used now in preference to plasters, but they are a
great deal more painful. When you have mustard plasters
to prepare, they are made with mustard mixed to a paste with
Leot. v.] lectures on NURSING. 99
cold or tepid water. A little flotir may be added, bat not
necessarily so. It is sometimes desirable to precede a mustard
plaster with a linseed- meal poaltice, or to bathe the part
to which it is applied with very hot water, in order to make
the mustard plaster produce its maximum effect.
Some people and books tell us that mustard plasters are
best made on brown paper, covered with brown paper or
muslin. I pi'efer tissue paper entirely. Several folds of
tissue paper make a sufficiently thick and satisfactory back-
ground for spreading the mustard on, and one piece folded
over the surface can be neatly doubled back over the edges.
Tissue paper is better than muslin, as the mustard cannot so
readily get through ; mustard plasters are not placed next to
the skin, and must not be made too wet. They should be
fastened on with two or three pieces of strapping to keep
them in place, and covered with a little cotton wool to absorb
any moisture, and prevent any soiling of such clothes as may
come in contact with it. Do not allow the plaster to remain
on long enough to break the skin or raise a blister, and bo
specially careful in this respect with children and old people.
With these cases it is best to remove the mustard plaster
rather quickly, and replace it by a linseed-meal poultice for a
time, which will render the mustard application effectual
without the risk of a troublesome sore. As a rule, have a
piece of linen spread ■with simple dressing or zinc ointment
ready to put on when you remove the plaster, as it relieves
the burning, tingling sensation, and then replace the cotton
wool over it.
There are several other kinds of poultices, such as carrot,
yeast, chlorinated soda, and so on ; but these 'are ordered
comparatively seldom, and it is best for you to have directions
from the doctor who prescribes them of the exact way in
which he wishes them made, as I am anxious for you, in the
first instance, to learn those things which it is absolutely
100 LECTUEES ON NURSING. [Lect. V.
essential you should know. In this, as in other details, I am
endeavouring to explain to you what experience proves to be
the best method to take for a general rule, but I do this
always with the understanding that in practical work you
obey the instructions of those under whom you. may be
immediately working for the time being.
( 101 )
LECTURE VI.
We have, for the present, finished our consideration of the
application of cold and heat as remedial agents. The last
detail that we spoke of was a mustard plaster, and we may
fairly consider that this leads us to the question of counter-
irritation. Under this head I should like to bring to your
notice especially the process of dry and wet cupping, leeches,
and blisters.
But, first of all, what do we understand by countex'-
irritation ? We mean the application of an irritant sufficient
even to produce inflammation to the surface, to counteract a
deeper-seated inflammation. Fortunately, it does not rest
with us to inquire in what manner this result is brought
about. We have only to deal with the plain fact that, some-
how or other, counter-irritation does produce this effect.
There are different degrees of counter-irritation ; first, a
mere increase of vascularity, i.e., the drawing of an increased
supply of blood to the surface, which I told you was one of
the results of a hot application, and as the normal amount of
blood in the body remains to all intents and purposes the
same in ordinary circumstances, the drawing of this additional
supply of blood to the surface implies the withdrawing of it
from some interior organs. Now this object may be attained
to some extent by the application of poultices and fomenta-
tions only, or aided by the addition of turpentine, etc., to these.
The same object can be attained to a greater extent by dry
102 LECTURES ON NURSING. [Lect. VL
cupping, and to a still greater extent by wet cupping and
leeches, as that involves the withdrawal of a certain amount
of blood, not only to the surface, but /rom the body altogether.
The second degree of counter-irritation may be an increase
of vascularity, combined with a certain amount of inflamma-
tion, such as is best illustrated, perhaps, by a mustard plaster,
which, as you know, not only increases the vascularity of the
part to which it is applied, but sets up a certain amount of
inflammation of the surface at the same time.
The third degree of counter-irritation produces true
inflammation, amounting to a blister, and wc will endeavour
to speak of all these in detail to-night.
First, then, let us turn our attention to the means of
applying the first degi-ee of counter-irritation, tho object
of which is to create a mere increase of vascularity, i.e., the
drawing of an increased supply of blood to the surface. The
simplest method of attaining this object is by poultices and
fomentations; but we have already minutely considered the
preparation and application of these. "We will now proceed
to the study of cupping and leeches.
Cupping is of two kinds — dry and wet. It is resorted to
somewhat less frequently now, for the most part, than it was
in former times, and it is not very often done by the nurse.
Still you should be competent to do it, if you receive orders to
that effect. There are glasses of various sizes made for the
purpose, which I dare say some of you have seen or will see
in the wards. In addition to these are required a spirit lamp,
spirits of wine, blotting paper,. cotton wool, a saucer for wet
cupping, and a scarificator.
The glasses are warmed, and should then have the air
exhausted from them by inserting pieces of wool or blotting-
paper dipped in the spirit, and setting them on fire in the
glass itself. Your finger should be dipped in oil and passed
rapidly round the edge of the glass before it is applied.
Leot. VI.] LECTUEES ON NUKSING. 103
After that the glass should be placed quickly on the selected
spot, and gently pressed on it, so that the edges may fit
closely to the surface, care being taken not to heat the glass
too much, lest the patient should be scorched. The skin "will
then rise within the glass, which can easily be removed when
desired by inserting the nail of the thumb under the edge of
the glass and pressing the skin downwards. This is dry
cupping, and is generally employed to relieve pain.
Wet cupping is performed in a similar manner except
that the glass is removed, and a scarificator immediately
applied to the part, and then the glass at once re-applied
as before. The hemorrhage can be readily stopped, when
desired, by a pad of dry lint. The usual site for wet-capping
is the loins, just over the kidneys, and it is generally used for
inflammation of those organs, but it is also of service in
relieving pain in other regions.
Leeches are used for the purpose of taking away a small
quantity of blood, and they must never be applied over any
large vessel. Sometimes it is difficult to get them to bite at
all, or to make them fasten on the desired spot. The part
should be washed perfectly clean with soap and water, and
that is often sufficient preparation. If they will not take, the
part should be moistened with a little milk, or sugar and
water, or a little prick or scratch be made, so that a drop of
blood will exude upon the surface.
The less the leeches are handled the better as a rule, but
unless they are applied in water they are best wiped dry with
a soft towel. Miss Wood recommends that they should be
kept out of water for a short time before they are used, and
considers that this renders them more inclined to bite. Dr.
Smith and Miss Lees, on the contrary, recommend their
application in water for the reason that water is their native
element, and that when they are cool and comfortable in it
they will settle at once. If they are very tiresome you can
104 LECTUEES ON NURSING. [Lect. VI.
put them in a wine glass full of water, cover it with a piece
of paper, and turn it upside down on the place where you
wish the leech to settle, putting a towel underneath to soak
up the water then, and when the leech has taken, you
remove the glass altogether. It is not, however, necessary to
do this unless the leeches decline to bite in the ordinary way.
If you want to apply a leech close to the eye, or have had
particular orders as to the exact spot upon which it is
desired to fasten, fill a test tube with water and put a leech
in it, or staff the tube half full of cotton wool and then put
the leech in. If you put them into this small compass you
must see that their heads and not their tails are at the mouth
of the tube, otherwise, as they have not room to turn round,
there will be no possibility of their fulfilling their mission.
Dr. Stoke says, " Take half an apple, scrape out the pulp,
and, placing the leeches in, invert the rind on to the skin.
Leeches thus applied will bite at once."
I have never tried this plan nor seen it ti-ied, but one can
readily conceive it to be excellent, as containing the leeches
in a small compass, and as being a soft, light material to
place against the patient ; whereas the rim of a wine-glass
might press rather heavily if it were not gently used.
When the leeches have once fastened to the required spot
they must be left undisturbed. When they have finished
they generally drop off, but if any of them should remain
sticking an unusually long time, they must never be forcibly
pulled away, or the teeth may be left in the wound. If it is
necessary to do anything, a little salt sprinkled on them will
cause them speedily to relinquish their hold.
Each leech is said to obtain rather less than one drachm
or teaspoonful, but warm fomentations will materially increase
this quantity if desired. If, on the other hand, there is any
difficulty in arresting the bleeding, the pressure of the finger,
a little dry linseed-meal sprinkled on the surface, a small pad
Lkct. VL] lectures ON NURSING. 105
of cotton wool or dry lint, a cold compress, or a little ice — •
any one of these things will probably be suflBcient to stop it.
If the bleeding persists after trying these remedies, a little
tincture of iron diluted, or a point of caustic inserted into
the leech bites is generally effectual, but you would not apply
these without orders from the doctor, unless you were nursing
a case in which it was not possible to obtain his assistance.
In most cases, where no special orders are given, when
the leeches are removed, just wipe over the wounds with
a bit of cotton wool, and leave a piece over the place. It will
absorb any slight bleeding that occurs, and is comfortable for
the patient. The nurse must see occasionally that no bleeding
is going on, for it may do so to a considerable extent before
the patient is aware of it. The night nurse should also watch
for bleeding after leeches, not that it is likely to occur, but
cases have happened where serious harm has been done from
the bites bleeding profusely during the patient's sleep.
Some persons have a peculiar tendency to bleed freely, and it
is well that you should be aware of this, in case you should
meet with any instances of it.
Some nurses and some patients have a particular dislike
to leeches, and feel quite afraid of them, while others, on the
contrary, do not mind them at all. Nurses who have this
dislike must endeavour not to show it, for the sake of the
patients, and be careful not to make them nervous ; and nui'ses
who have no personal objection to leeches must not be un-
mindful of the feelings of those who have, and avoid teasing
them, for I am inclined to believe that the sort of unreason-
able horror which some people have of these harmless little
creatures is by no means nonsense or affectation, but a kind
of innate aversion to them which cannot easily be overcome.
After the leeches have been used they should be put
with a little salt, which will pause them to vomit the blood,
and they can then be placed in fresh cold water, which will
106 LECTURES ON NURSING. [Lect. VI.
require changing- occasionally if they are to be kept in the
ward.
The second degree of counter-irritation may be an increase
of vascularity combined with a certain amount of irritation,
such as is illustrated by a mustard-plaster, which, as you
already know, not only increases the vascularity of the part
to which it is applied, but renders it very sensitive, and sets
up a certain amount of inflammation of the surface.
' The third degree of counter-irritation produces true in-
flammation, amounting to a blister. Blisters may, of course,
be produced by the careless administration of almost any of
these hot applications ; but even if an accident of the sort is
not attended with any special harm to the patient, thai
fortunate circumstance does not exonerate a nurse from
blame if she lias produced a blister by the way sh.e has
applied an agent that was only intended to act as a counter-
irritant in a minor degree, or perhaps not designed to procure
that effect at all, for poultices and fomentations are more
frequently ordered for other purposes, and stronger measures
are used when counter-irritation is desired.
Blisters, as such, are produced by the ordinary blister
plaster, or by painting with a blistering fluid. The latter is
the least uncomfortable, for when the fluid begins to accumu-
late underneath the cuticle, the sticking of the plaster on
the skin round the surface where the blister is placed greatly
increases the discomfort. For this reason it is best not to
apply blisters with strapping, [or at any rate witb only one
piece to keep it in place, and cover it with some cotton wool.
If the blister has been applied on a plaster it must be
removed very gently when the cuticle has risen, for the part
will have become extremely tender. Before painting with the
blistering fluid it is a good plan to define the extent of surface
which you intend the blister to cover with a slight outline of
olive oil. This, with a little care, has the happy effect of
Lect. VI.] ' LECTURES ON NUESING. lOT
pi'eventing the blistering fluid from spreading beyond the
desired spot. Probationers have often to learn at the cost of
some discomfoi-t to the patient that if a little of the fluid
runs down by the side of the place to which the blister is
being applied, wiping it rapidly does not prevent the irrita-
tion extending to every spot with which the fluid has come
in contact. It is especially useful to employ the oil and
prevent any accident of the kind in nursing children.
There are cases in which the oily matter of the skin
prevents the blister from rising. This difficulty in the rare
instances in which it occurs can be overcome by wiping the
place to which the blister is to be applied with a little ether.
The time a blister takes to rise varies in different people and
in different parts of the body, from six to twelve hours, but
the nui-se should watch its progress from time to time.
Sometimes the blister is very slow to rise, and then a warm
poultice should be applied over it, which will materially aid
the process. The exact spot and extent of the blister should
be definitely ordered by the doctor, but sometimes the order
is given so vaguely that a nurse is rather puzzled what to do.
Of course in the wards you can always ask the sister, but for
those who are private nursing, for instance, it may be useful
to know that, as a rule, blisters applied to joints are more
effectual if placed in the region of the joint and not imme-
diately over it. Thus, a blister for the hip- joint is most
effectual if applied in the region of the gi-oin ; for the knee-
joint if applied in the shape of two half-moons above and
below the knee-cap ; for the ankle if put between that joint
and the heel, and so on. To dress the blister, place a small
receiver, or, if the blister is very small, a towel or a piece of
lint or wool close underneath to receive the fluid, and then
make a snip at the most depending part of the vesicle. Press
very gently over the raised cuticle, and see that all the serum
comes out. After which, apply the dressing — usually simple
108 LEOTUEES ON NURSING. [Lect. VI.
dressing, olive oil, or zinc ointment on linen or lint over the
inflamed surface without removing the cuticle ; Tbe sure you
have it ready, and not keep the patient waiting while you
go off to get it; the part will generally heal rapidly. It
must be kept clean, and the dressing renewed twice or more
if necessary, in the twenty-four hours. If it is desired to
keep the blister " open," which is not very often the case,
remove the raised cuticle with a pair of scissors and dress
the place with the irritant application ordered, but be careful
that this is the exact size of the sore. A piece of lint spread
with simple dressing or oil a little larger than the sore, should
be placed over the other application, and strapped on to keep
it in place. The wound must be kept clean, and the dressing
re-applied daily until further orders.
I think that is all that I have to bring to your notice in
connection with a nurse's duties when counter-irritation is
the treatment prescribed.
The next detail of nursing to which I am desirous of
calling your attention is one which has to be kept in such
constant remembrance by the nurse, that I can hardly avoid
mentioning it in connection with the special nursing of every
case, and so, to spare you repetition, we will consider this
matter separately — I mean the risk, prevention, and cure of
bed-sores. They are the terror of all good nurses, as most of
you know, and with sufficient reason, for, in the first place,
they are the source of the greatest distress, pain, and discom-
fort to the unfortunate patient ; and, in the second place, in
nine cases out of ten they are the result of carelessness and
neglect, or at any rate they occur from the want of sufficient
care on the part of the nurse. There are cases in which no
amount of care can prevent them, but these are comparatively
exceptional, and it is well for all nurses to consider them so.
Doubtless you will have a useful and interesting lecture on
this subject later on, therefoi'e I shall not take it very fully,
Lect. VI.] LECTURES ON NURSING. 109
but as I feel it is impossible to speak of the trained nursing of
operation, accident, and many medical cases, without dwelling-
upon this important item, I cannot pass it over here altogether.
Bed-sores are the result of pressure, as you all know, there-
fore a nurse's object is to relieve pressure on all the more
prominent and sensitive parts. The lower part of the back
and the hip bones are the parts needing most care and watch-
ing as a rule, but in certain conditions bed-sores will also
occur on the heels, elbow^s, knees, ankles, if these joints are
in such a position as to come in close contact with the bed or
pillows. The next thing to be avoided is moisture, for that
is the second condition that Avill speedily induce bed-sores
unless it is very carefully guarded against ; and moisture,
when combined with pressure, materially increases the ten-
dency to them.
A nurse's business chiefly lies in the prevention of bed-
sores, for in most cases the surgeon prescribes the treatment
when the sore has occurred. You all know the necessity for
keeping the patient as dry as possible. If this is not done
other means are useless. Be very careful but very firm about
this point, and use all your ingenuity in difficult cases to
attain this all-important object of keeping the patient per-
fectly dry. Now, in cases where the patient is lying in one
position long, you must not wait uutil some signs of redness
appear before you begin taking the necessary precautions.
You must guard against the tendency from the very first, as
an evil that will inevitably attempt to come, if it does not
succeed. It is good to cleanse the parts thoroughly with soap
and water, and afterwards powder them freely with zinc powder
or starch. Some doctors do not approve of washing with
soap and water, and when you have orders to the contrary,
you have only to obey, and avoid criticising them ; but I am
now giving you general rules for your own personal guidance
when these matters are left to you.
110 LECTURES ON NURSING. [Leot. VI.
Spirit is extremely useful, and should be freely rubbed
into and allowed to dry into the part vjhen the shin, is not
hrohen. When it is broken, continue to rub the neighbouring
parts with spirit, carefully avoiding the sore place. Some
nurses forget to continue this when a sore has begun.
A very effectual way of applying powder and spirit when
you are dealing with a tendency to bed-sore is to moisten
a piece of cotton wool with spirit. Dip this into the powder
and rub it on. If the skin breaks very little, white of egg
is an excellent thing to prevent its getting worse, and it
forms a healing sort of glaze over it. Zinc ointment, oil, and
spirit, and any greasy application rubbed freely over the
parts is excellent where the nature of the case makes it impos-
sible to maintain more than comparative dryness. Of course
water rolls off the greasy surface, and neither moistens nor
irritates it to the same extent. Never forget the possibility,
and in many cases the probability, of bed-sore ; use all your
efforts to prevent it, but remember that the earliest evidence
of one must be reported and shown to the doctor. Nothing
can excuse any neglect of this rule. The condition of a bed-
sore is sometimes an index to the state of a patient's condition
in other respects. Some doctors leave the treatment of mild
bed-sores in the nurse's hands, some prescribe for it them-
selves ; but take care that you always leave the responsibility
with them.
Another good plan is to rub a mixture of olive oil and
some sort of spirit over the tender part for at least five
minutes, two or three times a day. The friction is of great
service as well as the ingredients rubbed in.
Collodion painted carefully in one layer over the part is
very useful ; it excludes the air and allows any slight sore to
heal naturally underneath it. But if applying this at night,
keep the light at a safe distance, for the ether it contains is
extremely inflammable, and I have myself known an instance
Lect. VI.] LECTURES ON NURSING. Ill
where the patient was badly barnt fi-om the nurse's careless-
ness in reference to, or her ignorance of, this fact.
In some cases a very good result is obtained by dusting
the sensitive parts with zinc powder and painting on one
layer of flexible collodion over this. This remedy is espe-
cially useful in those cases where the constant difficulty is to
guard against moisture.
Some surgeons order amadou plaster to be applied with
a hole cut in the centre, the size of the sore, to relieve it of
all pressure, and when this is ordered of course you will have
an opportunity of seeing the effect of it. For the most part
I think you will find that this treatment has a tendency to
make the surrounding parts tender also. Small circular
pillows made with a hole in the centre are most useful for
protecting sores where they exist, or the place where they are
likely to occur.
The dressing of bed-sores nearly always falls to the nurse's
share. Zinc dressing, carbolic oil, resin, iodioform, gall oint-
ment, tincture of benzoin, and nitrate of silver are all suitable
for varied cases of bed-sores. "Water pillows are very desirable
for cases where bed-sores are to be anticipated ; indeed,
paralyzed and dropsy cases should invariably be supplied
with them fi-om the first, if possible.
Remember that crumbs in the bed, wrinkles in the bedding
and blankets placed under the bottom sheet are all conducive
to bed-sores.
I think there is still time for me to say a few words to
you in connection with the subject of accidents and emer-
gencies— always bearing in mind that these matters will be
brought before you much more effectually and in far greater
fulness later on.
The first thing you have to consider — supposing the
accident beds to be all ready — is the method of undressing
the patient so as to avoid unnecessary pain or increasing the
112 LECTURES ON NUESING. [Lect. VI.
extent of the injury. Unskilful handling of a simple fracture
will easily turn it into a compound fracture, for instance.
Perhaps I should explain, for the benefit of those who are
quite new to hospital work, that a fracture is termed
simple when the bone is broken and the skin remains un-
injured, and compound when the broken bone has pierced
the skin.
Cases of fractured femur are perhaps the most difficult
to undress. The bedclothes should be turned back to the foot
of the bed, and the patient laid in the middle. The coat,
waistcoat, and collar should be removed iirst, as gently and
expeditiously as possible. The outside seam of the trousers
of the injured leg should then be ripped up, waistband in-
cluded— and take care that the buttons of the braces are
unfastened at the back as well as the front, to avoid all
dragging — then throw a sheet lightly over the patient, to
prevent any exposure, and the cut trouser leg must then be
drawn, with the utmost care, from under the whole length of
the leg to the inside, slipping your hand gently under the thigh,
if necessary, to guard against any jerk. You can easily draw
off the leg of the trousers of the uninjured side, while the sheet
is still over the patient. The stockings must be cut down the
seam to the foot, and then taken off without a jerk, by
keeping one hand firmly on the ankle. If it is a broken arm,
a dislocated shoulder, or any injury of the upper extremity,
remove the sleeves from the uninjured side first, if it can be
done without causing much pain; but if not, the outside
seam of coat, waistcoat, and shirt must be ripped up.
Never risk increasing the injury by refraining from
cutting the clothes ; but the destruction of clothes is a matter
of great importance to poor people, and must not be done
I'ecklessly. Cut tapes and buttons, bootlaces, and hooks and
eyes freely — these can be quickly replaced — but never destroy
material when it can judiciously be avoided. Women know
Lect. VI.] LElCTtfRES ON NURSING. 113
how to undress a woman, but take care and ascertain that
all buttons, strings, etc., are freely unfastened before you
attempt pulling them off. In all cases undress the patient
as though the injury were of a serious nature ; avoid jerks
and pulling. Before taking off the boots, take a firm hold of
the ankle, so that there may be no strain above that. Be
sure and see that the garters are removed before attempting
to draw off the stockings. It seems ridiculous to point out
this, but nurses sometimes forget it. In putting on and
taking off clothing from patients where movement is a
difficulty, lay down for yourselves the distinct rule, " Never
make two separate moves where one would do," and then
reduce this to practice in each case, with all the common
sense that you possess.
Remember, if you ai'e putting on a clean shirt or night-
dress, the bad side must be attended to first ; if you are
taking it off, take out the uninjured side first, so that there
may be no difficulty or strain in getting it off the bad side.
Never touch any wounded limb as though you were afraid
of it ; handle it very gently, of course, but quite firmly. A
hesitating hold will fidget the patient, give unnecessary pain,
and inspire no confidence. While I am speaking of moving
people, I had better remind you that if you have to lift or
carry patients with injuries or diseased limbs, as frequently
happens in the case of children, that the bad side must
always be carried the furthest away from you, and the un-
injured side next to you. Do not forget this, for you are less
likely to hurt in this manner, and it looks " untrained " to do
it the other way.
If you are putting to bed hip disease cases, for instance,
the patients are frightened at the pain which the least
movement causes them. Let them put their arms round
your neck to support themselves ; or, if it is only a question
of raising themselves in bed, they can do it with the pulley ;
I
114 LECTURES ON NURSING. [Lect. VI.
and turn all your attention to keeping the limb absolutely
straight. It is best to take a firm hold of the leg above the
ankle, making a little traction at the same time ; and, as you
do not want to throw any increased weight on the inflamed
joint of the hip or knee, whichever it may be, keep the head
low and resist the tendency to raise it. When yon have the
patient in your arms, remember, if you are assisting in
putting a patient straight and comfortable in bed, and are
asked to raise him, go on the tminjured side !
Now, when you have succeeded in undressing your patient,
and he is safely in bed, the next thing is to get him thoroughly
clean, particularly the injured part, as that is what the doctors
will want to deal with first. Patients are generally very
dirty in accident wards. Often they are brought in straight
from work of a dirty nature. Sometimes the shock of the
accident may make it imperative not to disturb the patient
at all, but in that case you must get orders on the subject :
that is the exception, and washing a patient thoroughly aa
soon as possible is the rule. You must guai-d against cold.
The vital powers of the patient will frequently be lowered
from the shock of the accident ; be especially careful to keep
this in remembrance with all cases of burns.
AH accident beds should be provided with a mackintosh
and draw-sheet to be put on the pillow, near the foot, or in
the middle of the bed, wherever it is needed. If there is no
necessity for it, it can easily be removed, but it should always
be there to begin with. It is useful for the washing process,
if nothing else, and it is dirty, wasteful, and moat careless on
the pai't of a nurse to let the bedding and matti-esses get
soaked through with blood before she thinks it necesgary to
see after a mackintosh.
Practures are placed on firm even beds. In some hospitals
fracture-boards are used — i.e., plain deal boards, the size of
the bedsteads — and in other hospitals straw mattresses^
Lect. VI.] LECTURES ON NURSING. Il5
under the hair mattresses, which should be placed over both.
The fracture femur beds in use in the wards will explain
themselves — at least, I need not say anything special about
them here.
Fractures should be placed between sand- bags until further
orders are given. If it is a compound fractui'e, watch care-
fully for bleeding, and in these cases have ready a basin of cold
water, sponges, lint, and collodion, in addition to the splints,
pads, bandages, cotton wool, strapping and sti*apping-tin,
which you would get ready for the sui^eon in simple fractures
also. In cases of fractured femur, the patient should lie upon
his back, and only have pillows so as to keep the body as
level as possible. In cases of fractured ribs, the patient will
be more comfortable propped up with pillows, and probably
will prefer to lie on the bad side, as in cases of pleurisy ; it
enables him to breathe with less pain. You know the fear
in all cases of fractured ribs is that it may be complicated
with injury to, or inflammation of, the lungs, therefore watch
for any cough or spitting of blood. Do not forget that when
the lower limbs are in splints, and are not slung up in a
cradle, you will have bed-sores on the heels if you do not
guard against them, and take the precautions I have already
mentioned.
In cases of concussion or lacerated scalp, there must bd
no shaking, no food must be given, and perfect quiet must
be maintained. You should have ice-bags and hot bottles
quite ready to apply the instant they are ordered. In these
oases notice if there is any discharge from the ears or nose.
There may be squinting, contraction, or dilation of pupils;
Kotice also if there is any pai-alysis, or if any convulsions
occur; if there is involuntary evacuations of the bowels or
bladder, or any vomiting. These things the nurse may be
the fii'st to notice ; but remember only to report the occurrence
of any one or more of these symptoms, and do not exceed
116 LECTURES ON NURSING. [Leot. VI.
your duty by any observation to the effect that they have
not occurred, except in reply to a direct inquiry from the
doctor.
Some of the cases that are carried in to you "insensible "
are in this condition from drunkenness. For these patients
you should raise the head a little and turn it on one side, for
the same reason that you do so for a patient under an
anesthetic — i.e., that is, to avoid the risk of vomited matter
being drawn back into the trachea and choking the patient
while he is in an unconscious state.
Many of your cases are complicated with delirium tremens,
I must not linger to describe the symptoms of its coming on
at length. Its advent is frequently characterized by bad
dreams, temporaiy wanderings, fussy excitability. Take
great care of the injured limb while the patient is in this
irresponsible condition.
Fainting comes under the heading of emei'gencies, if not
of accidents. It is caused by the temporary failure of the
heart's action, and the consequent cessation of circulation in
the brain. Lay the patient flat — to facilitate the flow of blood
to the head — and avoid the common mistake of raising the
patient. Secure plenty of fresh air, and at the same time
guard against cold. Consciousness gradually returns. The
distinctions between the insensibility of fainting, of drunken-
ness, of concusssion and of compression of the brain, cannot
fail to be very interesting to you, and will doubtless be
pointed out to you in detail by-and-by.
The occurrence of erysipelas is always to be dreaded in
accident and surgical wards. It is no part of a nurse's
business to diagnose this. Do not say to the doctor, " I think
such and such a case has erysipelas becaiise of so and so ; "
but it is desirable for you to know the symptoms of erysipelas
setting in, that you may not fail to notice and report them.
Redness round the edges of the wound, vomiting, rigors,
Leot. VI.] LECTURES ON NURSING. 117
the temperatiu'e rising, are among the chief. If from what
you hear or see you have reason to suppose erysipelas has
occurred, it is your duty to take every precaution against
carrying the contagion to your other patients. Therefore,
quietly dip your hands in carbolic acid, and be most scrupulously
careful about cleansing and disinfecting any instruments,
appliances, or utensils that have been used by or for this
case. Do not, for instance, put the bundle of wool, etc.,
carelessly on the bed whilst doing the dressing, and then
carry it off to another bed. If you can manage to dress all
your other cases first and leave the doubtful one to the last,
so much the better. If the case is pronounced erysipelas it
will at once be removed from the wards, and then you will
only have to be most conscientious in clearing away all
bedding, curtains, etc., washing the bedstead with carbolic
acid, and taking every precaution that no trace may remain.
I think this is all I have to say to you in connection with
this branch of your work.
118 LECTURES ON NURSING. [Leot. VII.
LECTURE VII.
To-night I propose to speak, in the first place, of a nurse's
duties in connection witli operations. We have to consider—
tlie preparation of tlie patient, the preparation of the theatre,
the duties of the nurse in the theatre, the after care of the
patient, and then a few details to be remembered for the
jiursing of special operation cases.
1st. The preparation of the patient.
Many of you know already, and all of you ought to know,
the importance of keeping the patient without solid food for at
least four or five hours before the administration of ether or
chloroform. In many cases beef-tea and brandy is given
much later than that, but not solid food, and you must not
give anything 'at all without permission to do so. Some
house surgeons give minute directions on this point, and then
you have no responsibility beyond carrying them out ; but
others take it for granted that a nurse is aware of this in-
variable rule, and will expect her to attend to it without
further reminder, if he merely says that a patient is to be
operated upon at a certain hour.
Be sure that you never fail, from any reason whatever, to
report the fact if the patient has taken solid food at a later
hour than the surgeon is aware ; to do so is to risk the
patient's life. If you have carelessly forgotten the order that
the patient was to be kept without food, let no fear of getting
blamed in the matter deter you from reporting the fact at
Lkct. VII.] LECTURES ON NURSING. 119
once ; or if the patient has succeeded in getting food in any
other way, you must let the sister know of it immediately.
Anaesthetics pi'oduce sickness, and the chief risk lies in the
vomit being drawn back into the trachea, when the patient is
under the influence of ether or chloroform.
An aperient is generally ordered the night before the
operation. In operations near the rectum, bladder, or vagina,
an enema is nearly always ordered in the morning of the
operation. In some hospitals there is a standing rule on this
point, but in others special directions are given in each case.
In every instance you should give the patients the oppor-
tunity of making themselves quite comfortable in these
respects the last thing before they are taken to the theatre.
When the patients are allowed to have a bath the night
before, it is a very desirable thing for them ; and if not, you
must always see that they are carefully washed.
All dressings must be removed, the wound, if one exists,
cleansed, and the place covered with a piece of lint, just
before the patient is taken to the theatre. The arm of the
nightdress on the side where the operation is to be must not
be put on — if the arm or breast is the affected part. Patients
should always have on their stockings, and when flannel
drawers can be worn, tcithout the slightest risk of their proving
inconvenient in the theatre, it may be done — for the twofold
reason of avoiding all unnecessary exposure, and of keeping
the patient warm. The patient's throat and neck should be
kept quite free, and the nightdress unbuttoned or untied, as
the case may be. It will mostly rest with the sister or nurse
to place the mackintosh, and great care should be taken that
this is done effectually, that the patient's clothing may not be
unnecessarily soiled. The patients should always be carefully
Avrapped up whilst being conveyed to and fi-om the theatre,
to avoid their taking cold. Keep the parts that the
surgeon is not immediately concerned with covered up in the
120 LECTUEES ON NUKSING. [Lect. YII.
theatre, that the vital powers may not he lowered unneces-
sarily by cold. You know that the tendency of aneesthetics is
to reduce the temperature of the body. If the patient uses pins,
or hair pins, habitually, you should persuade her to dispense
with them on this occasion, as the patient frequently struggles
violently in taking chloroform or ether, and they may hurt
her or her attendants. You must also he careful to inquire
if your patient has any false teeth, and see that they are
removed prior to the operation.
But this is not quite all that a nurse should do for her
patient by way of preparation, though perhaps it is all that
can be technically demanded of her. I hope that none of yoti
will feel that you have done your whole duty without sparing
a little cheering and encouraging sympathy to help your
patients through the ordeal awaiting them. It is a tempta-
tion, amidst the numberless cases which constantly fill the
wards, for hospital nurses to forget that what is to them in
hospital phraseology, " another breast case," "an amputation,"
and so on, is naturally a very different thing to the unfortunate
patient who has to meet the trial in his own person. There
is no hai'm in thinking and speaking of cases in this general
sort of way, but it will be bad for yourselves in the end, as
well as for the patients, if you lose your care and interest in
the individual. Take care that you do not grow hardened in
this way. There is no time to waste in much talking, neither
is it necessary ; but the few minutes that you must bestow in
preparing your patient in other ways will give the opportunity
for the few encouraging words that means so much to them
if they are spoken at the right time.
Try and put you rself in their place, and think as far as
you can what you would like said to yourself on such an
occasion. Never say what you do not believe to be true, but
do take the trouble to say every encouraging thing that is
true, and which can help the sufferer to look forward hope"
Lect. VII.] LECTURES ON NURSING. 121
fully to the result. If you have known apparently similar
cases "get through" well, you can cheerfully mention the
fact. If yon have reason to believe that the surgeon who is
to operate is specially clever, a quiet remark to that effect will
give the patient increased confidence. Never confide your
doubts and fears to a patient — that is not kind, nor necessary.
They may or may not be well founded, but you can do no
good by depressing the sufferer. Neither would it be right
to give false hopes ; but you will earn much gratitude and be
doing right if you let your patients feel your interest in a
quiet womanly way, and surely it is a nurse's privilege " to
comfort and help the weak-hearted," as perhaps only she can
do on such occasions. Every one, almost without exception,
will be secretly craving for this sympathy, though perhaps
they may give no evidence of such being the case. For the
most part patients are very brave. Remember that I do not
want you to chatter a great deal, and talk too much to them
about their trouble, only just to do unto them as you would
yourself wish to be done by under similar circumstances.
The theatre should be kept fresh, though not cold. From
65° to 70" Fahr. is the i-ange of temperature for ovariotomy
and lithotomy cases, but it is best to get directions from the
surgeon in each case, as it is one of the details about which
they frequently differ. The instruments do not, as a rule,
come within your pi'ovince, but it is well for you to notice
them as you have opportunity. They should be covered with
a towel, that the patient may be spared the sight of them.
In those places where the needles are threaded by the
nurse, she must remember to have a good supply ready
threaded, with whatever sutures the surgeon has ordered. In
your dressing basket, or arranged on a table according to the
custom of the hospital, you must have a supply of lint, cotton
wool, strapping ready cut, bandages of all kinds, gutta
percha tissue, drainage tubes, pins, broad and narrow tape.
122 LECTURES ON NURSING. [Lect. VII.
needles, and towela. You must also be provided with olive
oil, carbolic oil, plenty of hot and cold water, which is usually
supplied, ice, brandy, morphia, a feeder, spoon, aad medicine
glass. Also a ball and hypodermic syringe, in case either may
be needed in an emergency. You will need plenty of empty
receivers for the reception of pus, dead bone, etc. Never
throw away any of these things until you have orders to do
so. A towel, receiver, and sponge is needed for the vomiting
which the anaesthetic nearly always produces. The patient's
head must be turned on one side to allow the vomited matter
to escape. A perfectly dry sponge may be asked for to place
inside the ether inhaler, so a nurse had better have one at
hand that has not been recently wetted.
Sponges must be thoroughly cleansed and wrung out of
cold or iced water as dry as possible. This is best done in a
towel. Some surgeons like their sponges wrung out in water
of a higher temperature, but then special orders will be
given. This is the chief part of the nurse's business, and it is
most important to do it well. If the operation is done under
the carbolic spray, the sponges, after being washed, must be
wrang out in ^V carbolic lotion, and the nurse must remember
that, in addition to the mackintosh that covers the table, two
mackintoshes in very good condition will be required to
protect the patient from the moisture from the spray.
A nurse must always have ready a basin of water and a
clean sponge, as it may be asked for at any moment, and is
often finally required to wash away the traces of blood before
the dressing is applied. Of course, in operations done anti-
septically, instead of water this must be ^^ carbolic lotion,
and for these cases the surgeons will require this to be ready
from the beginning for them to dip their hands in.
Nurses are not there to see the operation, remember, but to
make their presence realized by the perfectly quiet way in
which all wants are foreseen or supplied. There must be no
Leot. VII.] LECTURES ON NURSING. 123
talking that can be dispensed with, even on business. Try to
catch every hint or suggestion quickly; never get in the
light. This is the time of all others for exercising quiet self-
control and intelligent observation. These directions apply
to all operations generally. For amputations, or where there
is a probability of much bleeding, a tray with sawdust should
be placed under the operation table ready for use. The narse
or probationer in the ward should always have the patient's
bed prepared for his return, hot bottles and blankets at
hand, all ready for use. Be prepared for the tendency to
vomit, and also for any symptoms of collapse, or any cessation
of breathing after the chloroform or ether. It is better for
the patient to " come to " gradually, if possible ; but if the
return to consciousness is too long delayed, water and a towel
must be flapped about the patient's face and neck.
After the patient has thoroughly recovered from the
effects of the anaesthetic, a nurse should I'emember that he
has been many hours "without food, and see that he has
suitable nourishment supplied as soon as it is allowed.
After all operations, hemorrhage must be carefully
watched for. There is always a possibility of it. Only
experience can teach you what is meant by " a little oozing,"
as it is called, and the beginning of more serious bleeding.
Place a towel or a piece of lint under the wound, in addition
to a mackintosh and draw-sheet ; so that, if you are in doubt
whether any stain is fresh or not, you can pull it on a little,
leaving the wound to rest in a clean place, and then you can
easily see if the bleeding is fresh.
If bleeding has begun, and the surgeon has to be called,
do not huriy away with the soiled sheets, etc., so that if
he desires to see the quantity of blood which the patient
has lost, he may be able to do so. If you are asked as to the
quantity, do not say " streams " of blood, etc., but try to give
the supposed quantity as accurately as you can. Remember
124 LEOTUBES ON NUESING, [Lect. VII.
that a little makes a great show on linen. Patients, even if
conscious in other respects, may be quite unaware that
bleeding is going on. If the patient can see for himself
when bleeding occurs, always impress upon him to let yon
know instantly, without making him nervous or frightened
about it ; and, of course, do not trtist to his doing so. Have
cold water, ice, warm water, sponges, and towels ready, in
addition to your usual dressing basket of lint, etc., and
have a fresh dressing ready to replace the one which will
probably have to be removed. Do not wait until the surgeon
appears before getting these things ready, as all delay is most
serious.
The method for arresting bleeding by. compression of
the artery with the various kinds of tourniquets, with
perchloride of iron, and the actual cautery, will be de-
scribed to you in detail later on — also the difference between
arterial and venous bleeding. If hemorrhage occurs from a
" stump," raise it, if possible, whilst waiting for the surgeons.
Have an empty receiver ready for clots of blood. Be ex-
ceedingly prompt, but do not get flurried, nor frighten the
patient. The less he or she sees of what is going on the
better ; and remember, he will keenly watch your manner, and
even the expression of your face, to try and ascertain if there
is any cause for alarm in a matter of such vital importance
to him.
Now we will go on with the subject of operations.
In amputation cases you will always have to watch care-
fully for bleeding ; so, in addition to the ordinary mackintosh
and draw-sheet, which you will, of course, leave under the
stump, it is well to have a towel or a thick fold of lint placed
so that you can easily draw it a little from time to time, and
ascertain if any fresh bleeding is going on. You must steady
the stump carefully with a piece of bandage over the pillows,
to prevent stai^ting. You will need a cradle to keep off the
Lect. Vn.] LECTURES ON NURSING. 125
weight of the bedclothes, and these must be so placed that
you can see the limb and watch for bleeding without disturb-
ing the patient.
Sometimes an ice-bag is ordered to be applied over
antiseptic or other dressings, to check the tendency to
bleed, and in these cases you must be specially careful
about changing it promptly, and never allow one to remain
on for a single minute after the ice has melted.
You will observe as a curious fact that patients constantly
complain of pain in those parts that have been amputated, and,
unreasonable as it sounds, the pain that they complain of is
very real. Remember to keep the patient warm and com-
fortable. Sometimes it is quite desirable to have a warm
bottle put to one side, when an ice-bag is ordered for the
other. A cradle is not conducive to the comfort of a patient,
except so far as the injured limb is concerned, and a small
blanket, under the cradle, should be ^vrapped over any other
parts that are likely to suffer from cold.
In cases of excision of the breast you must remember that
the arm of the side affected must be carefully bound down to
the side, and that the patient must not be allowed to use it on
any pretext whatever. The nurse must not forget that con-
siderable hemorrhage may take place without being apparent
under the large dressings frequently employed for these cases,
so she must watch the more carefully on account of this
difficulty, and should not fail to notice any change in the
pulse, or any increasing pallor of the patient, which may
indicate that bleeding is going on.
Cases of excision of tongue need very careful watching
and constant attention. The nurse must endeavour to
anticipate her patient's wants in every way, and not give him
the exertion and excitement of trying to make himself under-
stood. The patient must be kept quiet, and made warm and
comfortable. He must be guarded from draughts, as there is
126 LECTUBES ON NUESING. [Lect. VII.
a risk of pneumonia in these cases. The mouth must be
gently, but efPectually, swabbed out with some disinfecting
fluid — usually Condy's fluid in some water — from time to
time, but this should not be done with sufficient frequency to
worry the patient. The mouth must also be rinsed out
occasionally with the same fluid, and great pains taken to
keep it as free from offensive discharge as possible. No
nourishment must be given by the mouth until the doctor
gives permission. Some surgeons allow a very small quantity
of iced water to be given, but others do not approve of this.
Again, some surgeons permit small pieces of ice to be folded
in very soft muslin, and put in the patient's mouth ; but this,
also, you must never do without orders. At first the nourish-
ment is usually prescribed in the form of nutrient enemata,
and these must be given regularly.
The nursing of a case of cleft palate requires the greatest
care in administering nourishment and in keeping the patient
from speaking and crying, or the operation will speedily
break down and prove useless. Some surgeons insist that
milk, beef-tea, or any liquid diet they may order shall bo
carefully strained through muslin before it is given to the
patient ; but it is not necessary to do this unless you i-eceive
special instructions on the point. The nurse must carefully
watch that no bleeding is going on, as the patient may
swallow the blood to a considerable extent, and there is the
risk of choking. For the operation tiny pieces of sponge,
fastened on little holders for the purpose, will be required,
and it may be the duty of the nurse to provide the hare-lip
pins. I have already told you that the strapping used for
these cases has to be specially cut for the purpose. As the
patient may not speak, a nurse should watch very carefully
to anticipate his wants.
Both skill and great attention are required for the efficient
nursing of tracheotomy cases, as the life of the patient in a
Lect. VII.] LECTURES ON NUKBING. 127
large measure depends upon the prompt assistance and un-
remitting care of the person in charge. With children it is
necessary to be doubly watchful, lest they pull out the tube
in a paroxysm of difficult breathing, or lie over it, and thus
prevent the access and escape of air to and fx'om the lungs.
Grown-up patients are easier to nurse, because they are
generally able to understand their condition ; but in nursing
them also you must be careful to forestall their wants as
much as you possibly can, without waiting more than you
can help for them to tell you.
For a tracheotomy case you will require a tent for the
bed. This is frequently made of cotton sheeting, cut the
requii-ed shape, and it may be bound round with a little
scarlet braid to give the bed a brighter appearance. This
serves to keep away all draughts, and to preserve an equable
temperature in the immediate neighbourhood of the patient.
It also condenses the steam — for a steam-kettle is generally,
though by no means invariably, employed, A ward ther-
mometer should be hung inside the tent, to insure the desired
tempei-ature being maintained. Where no special orders are
given, this should be from 65° to 70° Fahr. The great object
in reference to the temperature which the nurse should keep
in view is maintaining it at all times, night and day, as
eqtial as possible. It is variations of temperature, either in
the direction of heat or cold, which have to be guarded
against. For this reason you should replenish the steam-
kettle with boiling water, so that the steam may be steadily
maintained without intermission, and not fill up the kettle
with cold or wai-m water, which must of necessity prevent a
pupply of steam for an interval.
You must have at hand a basin of water, and sponges,
feathers, olive oil and glycerine, lint and cotton wool ; tape
or flat white elastic for fastening in the tube ; a receiver^ in
case of sickness ; a soft towel and the tracheotomy instruments
128 LECTURES ON NURSING. [Lect. VII.
should be close at hand, but out of the patient's reach, and
covered up out of sight also. The neck mast be kept
thoroughly dry and clean in feeding the patient; milk is
apt to spill, and becomes soar on the patient's skin, and
possibly the moist atmosphere has a tendency to make the
neck get sore. You will always be shown exactly what
you are expected to do. Try and be most carefal and
intelligent in your observation and accurate in your report,
for you can be of the greatest service ; and, above all, if
the outer tube comes out, or any other unfortunate accident
happens, remember that life may literally depend upon
your presence of mind, self-control, and promptitude. You
will very soon learn how to remove, clean, and replace the
inner tabe with facility ; but perhaps I shoald warn you
always to replace this tube immediately, and never to let it
be out longer than is needfal for cleansing purposes. It may
be that the patient may have the appearance of breathing
better with the somewhat larger aperture, but this must not
lead you to forget that if the outer tube becomes clogged
with mucous, you have not the same power of removing and
cleaning that, and the patient may thus very shortly be in
danger of saffocation.
The only other detail it occurs to me to mention in con-
nection with the tube, is the care you must exercise that it
is not suddenly jerked or coughed out while you are renewing
the tape or elastic with which it is fastened. You should,
as far as may be practicable, pass the fresh tape or elastic
through the fastening before removing the other. I have
said that you will require feathers, and they must always be
at hand, but their use shoald be restricted as far as possible.
Some nurses get into a habit of poking feathers into the
tube on all occasions, with more vigour than discretion, for-
getting that such a proceeding is apt to irritate the trachea,
and is, moreover, quite unnecessary. Nevertheless, a feather
Lkct. VII.] LECTURES ON NURSING. 1^^
judiciously applied can be of great sei'vice in removing mucus
that is clogging up the trachea and the entrance to the tube,
and there are times when nothing else is equally well adapted
for tbe purpose.
Sometimes small pieces of flannel wrung out of hot water
are ordered to be placed across the tube. These fomentations
must be frequently renewed, for of course they cannot be
covered up with any waterproof material.
The three distinct objects which a nurse must always
keep before ber in taking charge of tracheotomy cases are-
keeping the tube free from mucus ; maintaining an equal
temperature; and the careful support of the patients' stx'engtll
by inducing them to take the nourishment ordered.
When you are nursing these cases, you must always be
careful lest in attending to the patient you catch by accident
any of the discharge, which is forced out from the tube with,
some violence, and which might be dangerous to you, should
the case be of an infectious nature. I may also take this
opportunity of reminding you that when you are nursing in
this warm, moist atmosphere, you should be careful to wrap
•np before you leave the ward, and to keep out of draughts.
You are likely to be more than usually susceptible to cold
under such circumstances, and, knowing this, nurses should
exercise some common sense for the preservation of their
health. Be sure and get a walk every day before beginning
your close attendance on these anxious but most interesting
cases.
There are one or two duties that it is essential for a
trained nurse to be able to perform efficiently, and I think
perhaps it will be easier to explain them clearly as complete
in themselves, than to break off in the midst of describing
the nursing of any special case with a view of making the
details to which I refer more clear to you.
I would first speak, then, of such offices as passing the
K
130 LECTURES ON NURSING. [Lect. VII.
catlieter, wasKmg out tlie bladder, and syringing the vagina.
If you understand, to begin with, how these things should
be done, I shall only need briefly to refer to either process
afterwards, without lingering to explain it over again in
detail.
One practical illustration in the wards of how to introduce
the catheter will make it much more clear to you than any
theoretical description ; but, as I do not like to pass the
subject over altogether, I will briefly quote the directions
which Dr. Smith gives on the matter.
" The patient should be placed upon her back, with the
knees drawn slightly up. The nurse should stand on the
right side, pass the left hand between the thighs, and place
the forefinger on the orifice of the vagina ; the catheter can
then be readily introduced with the right hand, and being
m.ade to glide over the finger of the left, will invariably enter
the urethra, and be felt through the walls of the vagina and
beneath the arch of the pubes, as it passes to the bladder."
I need scarcely remind you that this must always be done
■with the utmost care and delicacy. You must never attempt
to pass the catheter merely for the sake of experience, nor
try to do so alone without the sister's permission, Avhich of
course she will not give until she feels assured you are
competent to do it. Try in this, as in all your other Avork, to
make your patient the first consideration, and to render the
exposure necessary for your instruction as little distasteful to
them as possible. Only practice can enable you to perform
this without uncovering the patient, and you must never
attempt to do it in this way until yon have become familiar
with this part of a nurse's duty.
After some operations it is by no means as easy to intro-*
duce the catheter as it is in the majority of cases, and unless
you obsei've carefully you may suppose the catheter has
reached the bladder when it has only passed into the vagina.
Leot, VIL] lectures ON NURSING. 13l
The catheter should not be introduced more than two inches,
and no pressure or force should be employed under any cir-
cumstances. Experience will give you the necessary know-
ledge and confidence, as nothing else can, and the more you
understand the more you will realize the necessity for taking
pains to become efficient over all these details of trained
nursing.
For parsing the catheter the nurse should provide herself
with a receiver for the urine, some olive oil — for of course
the catheter must be well oiled before using — and a tov^el.
Be sure and leave the patient pei'fectly dry and comfortable.
To wash out the bladder, and to inject some fluid into it, is
sometimes an order which a nurse has to carry out. Extreme
gentleness is necessary, for you may do serious injuiy by
using the least force in any way. The neatest way is to have
a full-sized catheter, or the end of a full-sized catheter with
a piece of indiarubber tubing joined on, and a glass funnel
fitted to the other end of the tube.
Of course you will first di-aw off any urine that may be in
the bladder. Do not forget that the end of the catheter must
be oiled before using, as much for this as for the ordinary
purpose. It takes two to do this gently and efficiently, as it
always should be done. One person to hold the funnel at the
required height to pour in the fluid by degrees, and to let it
escape slowly from the bladder from time to time by lowering
the funnel into a vessel placed to receive the contents ; the
other to attend to the catheter, which must not be moved at
all until the process is quite over. The other method of
managing this is to put the end of the catheter on to a
syringe. The objection to this is that the fluid is necessarily
jerked in instead of flowing in steadily ; but, as some doctoi's
prefer it, it is well that you should be acquainted with both
ways — remembering that when you have no distinct orders to
the conti-ary, the former method is best.
132 LECTURES ON NURSING. [Lect. VII.
la reference to vaginal injections, I cannot do better than
quote the directions -which Dr. Oullingworth gives in his
"Manual of Nursing." He says, "They are usually ad-
ministered by means of a Higginson's syringe, to which
has been attached a vaginal tabe. This tube, which should
be made of hard rubber, is sold with the syringe ; it is a
straight tube five inches long, with a number of little holes
pierced in the sides of its olive-shaped nozzle. , . , The
proper mode of using it is as follows : The patient lies near
the edge of the bed, on her back, with a round earthenware
bed-pan underneath her to receive the returning fluid. The
knees are drawn up ; the nozzle of the tube, previously oiled
or anointed with vaseline, is passed under the [right knee and
so into the vagina, the end being directed towards the upper
and back part of the canal. The patient herself can hold
this part of the apparatus in position, while the nurse, having
placed the other end in the jug or basin which contains the
fluid to be injected, and which has been conveniently arranged
close to the side of the bed, gently compresses the pump of
the syringe, allows it to refill, and empties it again, and so
on until the desired quantity has been slowly injected. In
withdrawing the nozzle, its point should be kept upwards to
prevent what fluid remains in the apparatus from running
out. The syringe, after being used, should be well cleansed
and hung up by a loop tied round its metallic end. Almost
any quantity can be injected by this method, the only limit
being the size of the receptacle. A vaginal douche has this
amongst other advantages, that a patient having once obtained
the proper apparatus, can easily dispense with the services of
an assistant. The best instrument for the purpose is one
known as the irrigator. It consists of a tin pail or reservoir,
capable of containing from one to four quarts of fluid, which
is made to stand on a wall- bracket] or chest of drawers, two
or three feet above the level of the bed. At the side of the
Lect. YIL] lectures ON NURSING. 133
pail, near the bottom, is an opening into whicli is fixed the
end of a long tube, furnished at its other extremity with a
stop-cock, and terminating in a perforated nozzle of vulcanite,
the perfoi'ations being at the sides of the nozzle and not at
the tip.
" Vaginal injections may be simple or medicated. For
cleansing purposes, either pure tepid (70° to 85° Fahr.) or
warm (86° to 100° Fahr.) water may be used, or some dis-
infectant solution — i.e. Condy's fluid, in the proportion of a
teaspoonful to each pint of warm water. Medicated injections
are only to be given when ordered by the medical attendant,
who will give all necessary directions for their use. Injections
of pure hot water (100° to 110°, and even 115° Fahr.) have
been recently much prescribed, especially for the relief of
certain local inflammations."
The nursing of cases of ovariotomy, one of the most
important operations of which you can ever have charge, will
serve in a great measure as a type of all other abdominal
sections, therefore we will enter fully into the nui-sing details
connected with it. If we take this as the one for general
guidance, it will be easy to distinguish afterwards the points
of difference for the nursing of the varied abdominal operations
respectively.
Whether you are called to the nursing of a private case
of ovariotomy, or whether you have the advantage of having
the patient under intelligent supervision in a hospital, you
will generally notice that she is recommended to live well
and to keep as quiet and cheerful as possible for some days
before the operation. Some doctors prefer the patient's
temperature to be taken night and morning during this time.
.Unless it is known how the patient tolerates morphia, the
surgeon occasionally orders one-sixth of a grain to be injected
hypodermically prior to the operation, that he may see the
effect. The patient should have a warm bath the night
134 LECTURES ON NURSING. [Lect. YII,
before the operation, as it is very important slie should get
no chill nor experience any unnecessary fatigue on the day.
Half an ounce of castor oil is usually given the night before,
and followed by a soap-and-water enema the next morning.
The enema is usually repeated about two hours before the
opei'ation. The nurse should pass the catheter once or twice
beforehand to ensure the patient getting used to the process,
and this should be done about ten minutes before the opera-
tion. If this is to take place at two p.m. a good breakfast
should be given about six or half-past six a.m., and some
strong beef-tea, though nothing solid, should be given about
half- past nine a.m. The patient's hair should be well brushed
and plaited in two firm plaits, as it may be some time before
it can be properly brushed again, and arranging it in two
plaits not only makes it easier to brush without disturbing
the patient, but prevents her having a hard lump at the back
of the head to lie on. The patient should have on warm
woollen stockings, long enough to come well up over the
knees, a night-dress opening up the back for the convenience
of getting it out of the way, and a short flannel jacket fasten-
ing in the same way. When the patient is ready a light
blanket should be thrown over her until the operation begins.
You will take care that the patient does not see the prepara-
tions for the operation, nor is made conscious of them in any
v/ay that can be avoided. You must have ready a mackintosh
and blanket for the operating- table, a smaller mackintosh
with an oval aperture the size of the proposed incision, with
a circle of strapping gummed, or better still, sewn on to the
under side of the mackintosh, with the adhesive side left free
to attach it to the patient. All the water and carbolic lotion
used will be required warm. Everything used in connection
with this operation should, if possible, be perfectly new. Allow
no sponge to be in the room except the new ones that have
been carefully prepared for the case, and accurately counted.
Lect. Vn.] LECTURES ON NURSING. 135
If the surgeon is ia any doubt as to whether all the sponges
have been removed from the wound it will be a satisfaction
to him to have this fact ascertained beyond all possibility of
doubt by having the sponges counted. About twenty sponges
are sufficient. There should be two rather large flat sponges
for pressing the abdomen, six or eight small ones on sponge-
holders, and the remainder should be of the size usually
employed in the theatre. You should keep one clean sponge
apart from the othei^, with some -^t^ carbolic lotion in readiness
to wash round the wound in the end. I should mention that
■^Tf carbolic lotion is used for everything, including the washing
of sponges, except for the spray, for dipping the instruments in
before using, and for washing the surface where the incision is
to be made prior to the operation. This should be done by the
nurse immediately prior to the operation, but in most cases the
surgeon will ask for it to be done again in his presence, and
he will require some carbolic lotion ready for him to dip his
hands into before he commences. You should have a little
chloroform ready on some lint to wipe ofE the mai'ks of the
strapping before the usual antiseptic dressing is applied. You
should have in readiness plenty of dry gauze pads of all sizes,
a roll of boracic lint, a wide flannel binder, say a yard and
a half long by half a yard wide, with a square of double lint
sewn over the portion that covers the back to prevent the
flannel cha6ng the skin. Some surgeons pi'efer a linen binder
sewn outside the flannel to give a firmer support, but you
would not do this without orders, which, indeed, should
always be given or asked for in every instance. Occasionally
a T bandage is employed to keep the dressing in place. You
will require new fomentation flannels and wringers, three
empty backets to receive the fluid, or perhaps more ; at least
two carbolic basins and a white receiver. You should also
have at hand, brandy, morphia, and the syringes required for
injecting them, morphia suppositories, ammonia, ice, and
136 LECTURES ON NURSING. [Lect. VII.
safety pins ; in sliort, the usual things required for operations,
with the addition of those that I have specially mentioned.
You will have warm towels in readiness in case they are
asked for. The temperature of the room is usually about
68° or 70*^ Fahr. when you receive no distinct orders.
The bed for a case of ovariotomy i-equires to be specially
made. There should, if possible, be two hair mattresses, oi-,
'at any rate, you must ensure a sufficient thickness to protect
the patient from any discomfort arising from coming in too
close contact with the bedstead. Over the bottom sheet you
should put a mackintosh and draw-sheet. There should be two
soft pillows for the patient's head and shoulders, and one firm
pillow to support the knees, and thus relieve all strain from
the abdominal muscles. There should be a square water
pillow, just warm, and not filled too full, placed ready for the
patient's back, and hot water bottles should also be ready for
use. As a nile, nothing cold is allowed to come near the
patient except the ice that she is usually ordered to suck. In
some hospitals a cradle is used as a matter of routine for
ovarian cases, and in others it is only employed if the patient
is suffering from peritonitis, or finds the weight of the bed-
clothes an inconvenience. Either way the upper bedclothes
are made to open in the middle. To do this neatly you
require two top sheets, and two top blankets. These should
be doubled and placed so that they meet in the middle of the
bed. In this way all unnecessary exposure of the patient is
avoided. The check must be put on over this in the usual
way, and of course it has to be doubled back when the clothes
have to be moved aside.
I am not sure if this description conveys a clear idea to
your mind, but I cannot explain it better without giving you
a practical illustration on a bed, and this you will doubtless
soon get in the wards. The catheter must be passed every
six hours, oftener if necessary. A specimen of the urine
Lect. Vn.] LECTURES ON NURSING. 137
must be saved, and the quantity measured. The temperature
is usually taken every four hours unless the patient is
sleeping, and the nurse is sometimes expected to take the
pulse and respiration night and morning. The nurse may
give nothing by the mouth — sometimes even ice is forbidden
— until she has permission to do so. The surgeon will give
orders on this point, and also tell you when to begin the
nutrient enemata. These must be injected very gently and
lukewarm. The patient is frequently troubled with flatulency,
and if you are giving the nutrient enema with a catheter and
a ball syringe in the way I have previously described to you,
it is best to pass the catheter into the rectum before attaching
it to the tube of the syringe, so that any wind maybe allowed
to escape. Attention to this detail may not only relieve the
patient, but may make the difference of the noui'ishment
given being retained or returned.
The bed must, of course, bo kept scrupulously clean,
smooth, and fresh; but there must be as little moving or
changing of the patient as is consistent with attaining this
object. Ovarian cases must not be turned on their sides
in the usual way for changing the sheets of helpless patients,
but the draw-sheet — the only part of the bedding that it
should be necessary to change at first — should be securely
pinned to the one that is about to be removed, and in
this way it can easily be drawn through if the nurse gently
inserts her hands under the patient's back and raises her
— not more than two inches — while the assistant attends to
the sheet. I need scarcely pause to remind you that one
person must never attempt to change the under sheet of an
ovarian case without help. The fresh bedding as well as all
changes of body linen should be put on warm, and chills
carefully guarded against. In all probability the bowels
will not act for some days, and then it will be safe for the
patieut to be raised on to the bed-pan. This must be wai-med
138 LECTUEES ON NUKSING. [Lect. VII.
with hot water prior to use, to avoid all shock from the
patient coming in contact with the cold, earthenware, and
a little oil should be rubbed round the edges to facilitate its
readily slipping into position if the patient perspires.
If there is any tendency to bed-sores a piece of oiled lint
or simple dressing can be gently inserted under the flannel
binder to keep the patient's back from getting rubbed. Much
of the success of the case, and a great deal of the comfort of
the patient, depends upon the perfect stillness in one position,
i.e. lying on the back with the knees drawn up for the first
few days. If the patient vomits, sneezes, or coughs, the
nurse must place her hand gently over the region of the
incision to give firm support, and keep up a steady pressure
until the patient is quiet again. You must spare no pains to
induce her to lie as still as possible. The most careful obser-
vation and accurate reports are expected from the nurse.
You cannot be too exact about every detail. The atmosphere
surrounding the patient must be kept as fresh and as free
from every bad smell as you can manage to have it, for the
welfare of these critical cases greatly depend upon their sur-
roundings. There must always be a ward thermometer in
the room, and the nurse must be careful to maintain the
temperature ordered. You will probably find that this varies
to a consideiuble extent; some surgeons preferring a high
temperature and plenty of hot bottles, and others being of
opinion that too much heat exhausts the patient's strength,
but on such points you can always ask for instructions, and
then obediently carry them out.
I believe that is all which it occurs to me to tell you in
reference to these cases. I will refer to the others more
briefly.
Hernia cases require the bed made in the way jusfc
described. The patient must be kept lying on her back,
and for this reason you will need to pass the cathetei\ The
Lect. VII.] LECTURES ON NURSING. 139
affected part must be carefully supported by the hand during
all convulsive movements in the manner I have just spoken
of. N'o solid food must be given, but as the feeding is
important you must be careful to induce the patient to take
the nourishment ordered, night and day. Ice is nearly
always prescribed for these cases. The doctor may wish to
see the vomited matter, as well as the motions.
Lithotomy cases also need the bed made with the divided
upper bedclothes in the manner that you now understand.
The nurse's chief anxiety in these cases is the prevention of
bedsores, and the difficult task of keeping the bed as dry,
clean, and as free from smell as possible. It is also important
to remember that nothing cold comes near him, that sheets
and blankets, however fi'equently they may be changed, must
always be warm. Some surgeons will only permit pieces of
old blankets to be used as draw-sheets, but others have no
objection to ordinary draw-sheets, provided they are always
kept dry and warm.
Sponges are required to absorb the urine, which will at first
flow thi'ough the wound. These must be kept scrupulously
clean, and frequently changed. They should be wrung out
in cold water and carbolic acid, not warm water, as it increases
the smell. They should be squeezed perfectly dry, to render
them capable of absorbing as much urine as possible, and so
that you may be able to judge pretty accurately how much
urine passes through the wound. The surgeon will expect
the nurse to be able to tell him when the urine begins to flow
through the natui'al orifice, and also when it ceases to flow
through the wound. Any appearance of blood in the urine
must be at once reported to the surgeon.
There are various methods of aiTanging the under part
of the bed for lithotomy cases. Proper mattresses, with a
hole in the centre, in which a vessel can be placed to receive
the urine, are made expressly for this purpose. This should
140 LECTURES ON NURSING. [Lect. YII.
be covered with a mackintosli, made also with a hole in the
centre, and placed in a manner to conduce to the comfoi't of
the patient, and to protect the mattress.
The nurse must be especially careful that the patient does
not take cold from the washings near the wound, which will
be needed to keep the skin from getting sore. Every con-
ceivable precaution must be taken against bed-sores. The
surrounding parts should be smeared with some greasy sub-
stance to resist the moisture, such as vaseline, gall ointment,
zinc dressing, or anything that may be considered equally
suitable for the purpose. I am sure you will all recognize
the necessity of making a patient in this distressing condition
as comfortable as you can. You must keep a careful look
out for hemon-hage or rigors. The occurrence of either
must be promptly reported to the surgeon, I should mention
that, in cases of lithotomy, lithotrity, and stricture, the blanket
which the nurse has in reserve to cover the patient after the
operation should be warm.
The only point to which I need call your attention in
cases of lithotrity is that the surgeon will expect all the urine
to be cai'ef ully measured and strained, and all the fragments
of stone reserved for his inspection. When jou have charge
of stricture cases you must guard against chills, see that the
bed and body linen of your patient is supplied warm, and
watch carefully for rigors.
In most uterine operations the special point you have to
keep in remembrance is that the patient must not be allowed
to stand or sit up for some days, though in other respects she
may feel and be quite well.
There are one or two details that perhaps I should mention
in connection with cases of ruptured pei-inseum. Most
surgeons prefer the knees to be tied together, but that is
a matter for them to decide, and you will merely be careful
that their wishes are carried out. The patient lies on her
Lect. Vn.] LECTURES ON NURSING. 141
side, and may be gently tui-ned fi-om one side to the other to
suit her inclination. The catheter must be passed regularly,
and care taken to avoid any drops of nrine getting into the
wound. The bowels are kept persistently confined. If there
is any inclination for the bowels to act before the doctor con-
siders it desirable, morphia suppositories are usually ordered.
These should be thoroughly and effectually passed up the
rectum. This is best done by gently pushing them in with a
well-oiled catheter or bougie, and thus you avoid distending
the anus with the finger, as is sometimes done. The patient
is not allowed solid food. When the doctor wishes the bowels
to be opened, enemas as well as aperients are usually pre-
scribed. An oil enema first generally helps to produce a
satisfactory result if you are permitted to give it. You must
on no account leave your patient a moment alone at this
critical time. It may be necessary to support the perinseum,
and the patient often suffers much pain.
It is possible that as private nui'ses you may be sent to
take charge of ophthalmic opei-ations, and as many of you
may not have met with any in your experience in the general
wards, I will just mention one or two particulars for your
guidance.
Cataract is the most important eye operation with regard
to nursing, as its success greatly depends on the care of the
nurse. It is very important that the patient's general health
should be in as good a condition as possible ; therefore, if you
have charge of the patient for some time before the operation,
see that he is as well nourished, and that he gets as much
fresh air. as possible.
You must take especial care to cheer your patients, and
remember that their condition of blind helplessness is very
depressing. The more they have learnt to like and trust the
nurse, the more service she will be able to render them ; and
when you reflect that the sight may be lost for ever through
142 LECTURES ON NURSING. [Lect. Vll.
carelessness on your parf., I am sure you will spare no effort
to ensure a good result.
Before tlie operation, see tliat tlie patient's head, face, and
neck are absolutely clean, tlie hair brushed back from the face
and, if long, plaited in two plaits, as the patient will not be able
to be washed or the hair brushed for a week. In other ways
the patient is prepared for the operation in the usual manner.
Small, One sponges will be needed at the operation. After
the operation the eyelid will be strapped down with two
small pieces of strapping. It is best to smear the eyebrows
with olive oil before doing this. Both eyes should be covered
with lint and cotton- wool, and bandaged firmly, then place
the patient in bed entirely in the dark.
Do all you can to obviate the tendency to sickness for the
first twenty-four hours. The patient must lie on Lis back
for the first four days. Unless otherwise ordered, give a
nourishing slop diet for the first eight days. When other
food is allowed, be careful that no hard crusts, etc., are given,
or anything that it would cause the patient the least effort
to bite.
In cases of cataract no opiates or alcohol must be given
without express orders. If the patient complains of much
pain soon after the operation, and if there is much swelling of
the eyelid, you will usually be told to apply a leech over the
temple, otherwise it is best not to touch the bandage until the
next day. Then repeat the same dressing that was applied
at the operation, very gently Aviping the eyelid with damp
cotton-wool, and drawing down the lower lid to let any tears
escape. You must notice the quantity of discharge to report
to the surgeon. As a rule, if the eyes are doing well, there will
be little or no discharge, and not much pain after the first
twenty-four hours. On the eighth day the eye which has not
been operated upon may be uncovered, but the other eye
must be treated as before until the sui'geou has seen it. You
Lect. Vn.] LECTURES ON NURSING. 143
will please observe carefully that these suggestions are merely
for your guidance when no orders are given, but be exceed-
ingly exact about obtaining and carrying out any instructions
you can get from the individual surgeon whose case you may
be nursing.
In cases o£ iridectomy (double) both eyes must be covered
up for a week. Then, as a rule, they may be uncovered, and
only a shade worn. They may be bathed with tepid or cold
water twice a day from the day after the operation.
In cases of iridectomy (single) both eyes must be tied up
at first with double lint and cotton-wool, but the one may be
uncovered the following day if the patient keeps in a dull
light for a week.
I think, after what I have said, you will soon learn all that
is needful for you to know in connection with the innumer-
able minor operations, that are constantly coming before you
in the wards.
144 LECTUEES ON NURSING. [Lect. Vllt.
LECTURE VIII.
In the beginning of these lectures we considei'ed the dis-
tinction between the nurse's work and the doctor's, and the
relation which they bear to each other in their work. I think
we have clearly kept before us the leading idea that it is the
doctor's part to lay down a system of scientific treatment, and
yoTirs to be the active agents in carrying this plan of treat-
ment into effect. You have also been told that treatment
usually presents itself under one or more of three aspects.
First, it may be necessary to provide an antidote to any
poison, and to remove all sources of hai'm ; secondly, the chief
consideration may be to place and to keep the patient in the
most favourable condition for self-cure ; thirdly, it may be
desirable to aid in treatment by drugs which experience or
experiment have shown to be efficacious. It is under this,
the third heading, that the subject of to-night's lecture comes.
Already we have discussed somewhat minutely the nurse's
duties in connection with the forms of treatment spoken of
under headings one and two. We have considered all that is im-
portant for a nurse in keeping her patient perfectly at "rest,"
i.e. of applying the treatment of " rest," general and partial.
We have also spoken in detail of the application, both
general and partial,' of such natural agents as heat and cold.
Now we come to the complicated subject of "drugs," for it
certainly is more difficult for a nurse to acquire, or even to
Lect. VIII.] LECTURES ON NURSING, 115
know what is the sort and extent of the knowledge necessary
or useful for her to acquire in this branch of treatment.
Drugs — bj that we understand the ingredients used for
making up medicine — are prescribed for the cure or relief of
disease. When we say the cure of disease, we mean really the
putting of the body into such a condition as will enable it to
recover itself — we do not mean that the drug directly cures
the ailment in question.
By medicine we mean any remedy given internally, in
whatever form ; therefore it is not accurate for a nurse to say,
" this patient has not had his medicine, but I have just given
him a pill, or a powder." Nurses sometimes get into a way
of thinking that_the term medicine only applies to a draught
or a mixture.
Drugs may be employed for one of three objects—
1st. As a direct antidote for some poison, as, for example,
chalk is given for oxalic acid poisoning.
2nd. To produce effects which experiment has proved they
will do —as, for example, digitalis (which is a preparation of
the ordinary foxglove, as some of you know) is definitely
known to produce distinct effects for certain affections of the
heart.
3rd. To produce effects which experience has shown they
will do, apart from experiment ; and we may take the familiar
example of a cup of tea as a remedy for some sorts of head-
ache. We know it will in many cases have the desired effect,
but of this and many other remedies, doctors can only tell us
that experience proves it, they cannot explain why, nor
demonstrate the fact definitely by experiment. This last is
called empiricism, or empii-ical ti*eatment. I need scarcely
say that I do not wish any of you to take to talking about
empiricism or empirical treatment, but they are terms that
you will so frequently hear used, that you may as well under-
stand what is meant by them.
L
146 LECTUKES ON NURSING. [Lect. YIII.
As scientific knowledge increases, the first and second
objects for whicli drugs are employed are developed. New
antidotes for poisons are discovered, and experiments almost
daily increase the knowledge of what effects can be produced
in that direction.
It is under the third heading — drugs given to produce
effects that experience and not experiment has proved they
will do — which has constituted the bulk of drug treatment
hitherto, though the vast numbers of drugs that were formerly
employed are now much reduced, and many in general use at
an earlier period are now never heard of.
Much of the effect of drugs will depend on the circum-
stances under which they are given. Whether before or after
meals. The state of the patient's health also influences the
effects of drugs. In addition to this there are special idiosyn-
crasies of individuals — some cannot tolerate opium, for example
— to be taken into consideration.
Doctors acknowledge this to be a branch which requires
much more information, and from the doubt abont the effect
of remedies springs many differences of opinion. The very
nature of the question renders it difficult if not impossible to
arrive at definite conclusions that can be accepted equally by
all. The public have great, almost unlimited, faith in drugs, as
is illustrated by quack remedies, and the abounding popularity
of them.
As a rule, drugs are given with a view of getting them
into the blood and circulating to the different organs. Some-
times they are given for their local action only. Drugs have
specific action, i.e. some act as antidotes for some poisons,
some act as tonics, aperients, expectorants, sedatives, and
narcotics, some cause sweating, some act as stimulants, some
as astringents, and arrest hemorrhage, some as emetics.
Medicines are prepared in a variety of forms, and may be
administered in the shape of draughts, small doses, pills,
Lect. YIII.J lectures ON NURSING. 147
powders, or lozenges. Formerly the most nauseous compounds
were prescribed and swallowed as a matter of course, but
latterly much pains has been taken to make drugs available
in the most effective and palatable form which can be devised.
If you compare the well-known brimstone and treacle, for
instance, to the perfectly prepared pills and lozenges of to-day,
you cannot fail to see what an advance has taken place ixx
this respect,
Now, drugs are introduced into the system by the mouth
in the various forms i-eferred to ; by the rectum, as in the
form of enemas, or suppositories ; by hypodermic injections,
by inhalation, and also by absorption through the skin.
The nurse's work in connection with drugs lies chiefly in
theu" accurate and skilful administration ; and there is also
much room for a nurse to aid by most careful observation of
the effects produced, as she has the best opportunity for
noting them.
It can scarcely be necessary for me to impress upon you
the paramount importance of absolute accuracy in the measure-
ment of any medicine you give, whatever form it may have
to be administered in. You are well aware that iu some
instances a slight inaccuracy may cause fatal results ; in other
cases it may not be of much consequence ; but the habit of
perfect accuracy is all important — absolutely essential — to
good nursing.
You should all learn the simple table of English measure-
ments, if you do not already know it. I mean the following :—
One minim = one drop.
Sixty minims = one fluid drachm (one teaspoonf ul) .
Eight fluid drachms = one fluid ounce (two tablespoonfuls).
J ounce = one tablespoon or four teaspoonfula*
Twenty fluid ounces = one pint.
And be sure you thoroughly understand the measure glasses ;
notice them againand again, until you are as confident that
148 LECTURES ON NURSING. [Lect. VIII.
you understand them as you are that you know the difference
between an ordinary tea and table spoon. Carelessness in
this respect is unpardonable, and the possible consequences
of error are terrible to. think of. It is hopeless for a doctor
to form a coi'rect estimate of the effects, if his prescriptions
are not rightly given according to orders. Always read the
label, no matter how familiar you may imagine that you are
with it. Almost every hospital has its sad story of accidents
. — which might so easily have been prevented — from neglect
of this simple rule.
This is another habit you must resolve to cultivate for
yourselves : carefully shake up those mixtures that have
thick sediments at the bottom of the bottle, and do not pour
the dose into the glass until you are close to the patient, and
he is quite ready to swallow it. Do not leave bottles un-
corked. Impress upon your patients that if they do not wish
to taste their medicine much, they must avoid touching it
with their lips, and take care they have a handkerchief or
Bomething at hand to wipe their lips at once. This precaution
will often prevent the medicine being vomited by patients
who are inclined to sickness. Never make your patient drink
off an unpalatable draught when his lips, mouth, and throat
are dry and ready to absorb quickly the first liquid that comes
in contact with them. He will taste it much less if his mouth
is moistened previously.
In considering all these details, your chief object is to get
the medicine taken properly, with as little discomfort to
the patient as care and skill can secure. There is much
scope for the " art " of nursing to be cultivated in this
direction, and you will not only spare your patients much
that is disagreeable, but may ensure greater success in
efficiently carrying out treatment, if you excel in the adminis-
ti'ation of medicine.
Between the doctor thinking of and prescribing a certain
LEct. VIII.] LECTURES ON NURSING. 149
drag, and the nurse getting that dx-ug into the patient, there
Is a considerable interval, and often the difficulties of carrying
out these orders are not much taken into consideration by the
doctor. You must study in each instance the best way of
meeting and conquering these difficulties. Not only children,
but adults — those who are conscious, as well as delirious
patients — Avill often refuse remedies from one and take it
readily from another. "Why ?
It is not only a difference in manner, but it is partly
owing to care in such details as the perfect cleanliness of the
glass — the avoidance as much as possible of forcing the dis-
agreeable smell upon your patient — by poking the glass
straight under his nose while you are persuading him to take
it, more especially if the odour is as offensive as that of
valerian, asafoetida, etc. The usual method of giving medicines
round the ward Avith a basin of water and towel is very good ;
but in this case leave any disagreeable smelling medicines to'
be given last, and do not victimize all the patients unneces-
sarily with the discomfort of having an offensive odour added
to that of their own medicine. Do not give effervescing
medicines in too small a glass, and make the patient or bed
in a mess, nor pour it out in such a way as to let all the
effervescence go off before the patient can sit up. Of course,
if the patient will not drink it in a state of effervescence, you
cannot help it, but take care that he has the chance.
Oils are the medicines most objected to, as a rule, and they
should be given with great nicety. They are best floated on
the top of some liquid — brandy, coffee, beef-tea, milk. Follow
the inclination of the patient in these details. Wash the glass
well round with the chosen liquid, and then pour the oil
carefully in the centre of it. Castor oil is best given on
an empty stomach ; and this is the general rule for most
purgatives. It is said that hot beef-tea, made very salt, dis-
guises the taste of castor oil better than anything else ; and
150 LECTUKES ON NURSING. [Lect. VIII.
this is the liquid I would recommend to vou for the pur-
pose. But in this instance the oil should be completely and
thoroughly beaten up with the beef-tea, and not floated on
the top of it. Cod liver oil is best given immediately after
food. It is usually taken without any of the vehicles em-
ployed for castor oil. Croton oil is comparatively rarely used.
The dose is from half a minim to six minims : it is given in
butter or on sugar.
Iron and arsenic are always best given after meals. I
mention this, though directions for hours and quantity are
nearly always given in each case. Ten, two, and six are the
most convenient times for four hour and " three times a day "
medicines when no orders are given.
Pills should be given in any way to suit the patient.
Large pills are easier to swallow than small ones. Powders
must also be mixed to suit the cases ; for small children
moisten your finger so that the powder can adhere to it, and
place it well back on the tongue. After administeiing emetics
you must have a vessel ready for sudden speedy results.
Now, in order to report fully and carefully the effects of
medicines, a nurse must understand to some extent the object
for which they are given, if only the broad classification of
aperients, tonics, astringents, narcotics, sedatives, and so on.
It is almost dangerous to tread upon ground so nearly
bordering on the line of where doctor's work begins and
nurses' work ends. Nevertheless, I recommend yon to study
some of the known effects of certain drugs, with a strong
warning that any such knowledge is for guidance, and not
for display, nor even for remark. Do not say to the doctor,
for instance, " I thought I had better tell you such and such
a symptom, etc., because the patient is taking such and
such a drug." With a few definite things you may imply
that, as aperients and narcotics, for instance, are given for
a distinct and visible object ; but you must carefully avoid
Lect. VIII.] LECTURES ON NURSI-NG. 151
this where the effects intended to be reached are more obscure.
It looks oflBcious and ignorant not only in knowledge of drugs,
but ignorant of the nurse's place and training, which is far
more deplorable.
Whe7i you have become acquainted with the effects of any
drugs, note for yourselves what you see of them in practical
use, and report their effects simply, without comment in any
shape as to what cause these effects may be due. The
chief object in view is to pi-event the doctor remaining in
ignorance of them. If you perceive certain things, and
believe them due to certain causes, of course you will not
alter the treatment on your own responsibility, but you will
take care that the doctor is duly informed before you con-
tinue it, and then you ^xi]\ have thoroughly done your part
as an intelligent help.
The giving of hypodermic injections is not likely to fall
to your share, until you have become much more experienced ;
but it is Avell to make yourselves as familiar as possible with
the process, and for this reason you should notice how it is
done when opportunities occur. Practical illustrations are
worth a great deal of theoretical instruction on this point.
Hypodermic is a Greek term, meaning "under the skin."
The Latin term " subcutaneous " means the same thing. To
give a hypodermic injection, pinch up a fold of the skin, firmly
thrust the point of the syringe in, horizontally, after having
dipped it in oil, and then slowly inject the fluid. In filling
the syringe be exceedingly careful that no air gets mixed with
the fluid. The orifice is so minute that the liquid will not
generally escape, but it is as well to keep your finger on the
spot for a minute when you withdraw the syringe. The
quantity injected is always so small that the solutions used
for the purpose are very powerful.
I need scarcely point out, and yet I must not fail to
remind you, how quickly fatal any mistake as to the quantity
152 LECTURES OK NURSING. [Lect. VIII.
or strength of the liquid employed would almost inevitably
be. The greatest care and most minute accuracy are indis-
pensable. In many hospitals the doctors will not permit
hypodermic injections to be administered by any but them-
selves, but other doctors think that there is no reason why
very experienced nurses should not be allowed to give them,
if they have been shown how, and are thoroughly trustworthy.
The custom in this hospital, as most of you are aware, is
for the sisters to give hypodermic injections whenever they
are ordered. No nurse or probationer is allowed to do so,
and I am glad to take the opportunity of making all new-
comers distinctly acquainted with this rule. At the same
time I am always glad when the night or day sisters give
you instructions on the point, and when they permit any one,
who appears to them sufficiently capable, to give the hypo-
dermic injection in their presence. But you must not allow
the fact of your knowing how to do this, individually, interfere
with the general rule that no nurse or probationer here is
permitted to give the hypodermic injections, and you will
remember that you have no right under any circumstances to
take upon yourselves the responsibility of making an excep-
tion to an established custom in this hospital. This fact is
no argument to prevent each one of you acquainting your-
selves with this method of administering drugs, every time
that you have the opportunity. Be sure, too, that you learn
to read the hypodermic syringe correctly, that there may be
no possibility of error when it does fall to your share to give
a hypodermic injection elsewhere.
One grain of morphia in six minims is a common strength,
and two minims, that is, the third of a grain, is very gene-
rally prescribed, but implicit obedience to directions is all
important in every case.
In giving a hypodermic injection care must be taken to
avoid putting the syringe into a vein.
lect. viil] lectures on nursing. 153
The fine point of a hypodermic syringe easily gets clogged
up, especially when the gelatine discs have been employed for
the injection, and it is then of no further use. To avoid this
you must be particular to clean it at once, before the fluid into
which it has been dipped has had time to dry on. Take care
to pass some clean cold water once or twice through it, and
it is a good plan when possible to keep a small piece of silver
wire through the point when it is not in use. With careful
usage a hypodermic sj-ringe will keep in working order for
some time, but not otherwise.
Brandy and other stimulants are sometimes injected hypo-
dermically, but this is almost always done by the doctor.
A larger syringe is, of course, required for this purpose.
Putting drops into the eye is a little matter that you may
often have to attend to. I mention it in order to call your
attention to the fact that anything dropped into the eye
should be put in at the outside comer, not the side next to
the nose. The reason for this is that in the outside corner of
the eye there is a gland continually secreting and pouring
out a fluid we call tears. This fluid lubricates the surface of
the eyeball, and then runs down a little tube, whose orifice
we can see at the inner comer of our eyes, into the nose. Con-
sequently, anything dropped into the outside corner of the eye
will suffuse itself over the surface on its way to the little tube
before mentioned, and that is what you want the drops to do.
Mortar or lime in the eye occasions great pain, and
injury also, if it is not speedily removed. If you have it to
deal with immediately, the eye should be well washed with a
tepid solution of vinegar and water (about a teaspoonful of
vinegar to two ounces of water) . The lid should be everted,
and all pai'ticles must be gently removed. A drop or two of
castor oil dropped into the eye after it has been irritated will
greatly soothe it.
Many drugs now employed for inhalation are administered
164 LEOTUEES ON NUESING. [Lect. VIII.
on a piece of lint placed in a wire respirator, and worn by the
patient constantly or according to orders.
Another method liked by some physicians is to heat a
small pot by burning the methylated spirit inside it, and
directly this has burnt out, pouring the exact quantity of the
prescribed drug on the hot surface and allowing the patient
to inhale the fumes thus immediately thrown off.
In speaking of inhalations I must not omit to mention
a very important drug, nitrate of amyl, which is occasionally
employed in angina pectoris and other serious cases. It is
an extremely powerful remedy, and must only be administered
in strictest obedience to orders.
The correct doses of niti-ate of amyl are prepared in little
glass capsules to ensure the exact quantity being given, and
as an effectual way of excluding this preparation from the air.
When required for use the capsule is wrapped up in a piece
of lint, promptly crushed by your foot or in any other con-
venient way, and then given to the patient to inhale from
the lint.
Inhalations are given in various contrivances made for the
purpose. Some are fatiguing, inasmuch as they necessitate
the patient keeping his mouth over the tube or mouth of the
vessel, and taking a distinct breath for the purpose of inhaling
the vapour. A better invention, used in some hospitals, is
Siegel's spray, for the purpose of impregnating the atmo-
sphere immediately surrounding the patient's mouth, which
enables him to inhale it without effort. Various drugs are
used for inhalations. Take care not to scald the patient,
either throu.gh the carelessness of having the steam too near
at a scalding temperature, or from having the whole apparatus
upset by him in a sudden struggle for breath or a violent
cough. Watch for faintness in some cases. Inhalations of
poppy-head water induce drowsiness. Patients should care-
fully avoid breathing cold air afterwards.
JiECT. VIII.] LECTURES ON NURSING. 155
The most critical inhalations ai-e those used as anaesthetics,
such as ether, chloroform, and others, but of these we will
speak in connection with their use at operations.
The absorption of drugs by the skin is a fact that it is
important you should be aware of, when you have orders to
use external applications containing mercury, opium, and any
other drugs equally likely to produce a serious effect upon
the system, so that you may be careful as to the quantity
applied at any one time.
We have yet to speak of the introduction of dnigs into the
system through the rectum.
Suppositories are small conical preparations of various
compounds, which ai-e inserted into the rectum or the vagina.
They act as astringents, and check the action of the bowels,
or they relieve pain. Patients can often apply these them-
selves ; but if there is any difficulty, the nurse must do it for
them. You have only to dip your finger and the suppository
into some oil, and introduce the suppository as far up as you
conveniently can.
Enemas are of various kinds, and given for various pur-
poses. They are used to procure the evacuation of the bowels,
for the relief of pain, for restraining diarrhoea and dysentry,
and for introducing medicine, stimulants, and nourishment
into the system, when it is impossible, or deemed undesirable,
to administer them in any other way. When an enema is
given to relieve the bowels, a copious injection must be used.
It usually consists of about a pint or more of warm water,
with sufficent soap rubbed down in it to render it creamy.
Soft soap is useful for the purpose, and prepares quickly.
The usual proportion is about two ounces of soft soap to a
pint of water. If a stronger 'remedy is required, half an ounce
or an ounce of castor oil or turpentine is genei-ally ordered,
and this, mixed with a small quantity of gruel, or of the soap
and water, should be placed in a separate vessel, and injected
156 LECTURES ON NURSING. [Lect. VIIL
first, the remainder of the enema should immediately follow
it, without the nozzle of the tube being removed from the
rectum.
In this way the most important part of the remedy
will be effectually given, whereas, if you attempt to mix the
castor oil or the turpentine with the full quantity of soap
and water, you will find that the castor oil or the turpentine,
being lighter than the water, will float on the top, however
well mixed it may be to begin with, and the chances are that
the quantity ordered will never be given at all. Moreover,
you will not easily cleanse the vessel, nor get rid of the smell
of the castor oil, if you attempt to make one large mixture of
it. Sometimes olive oil is ordered, and that should be given
in the same way, as oil and water do not amalgamate. For
giving these enemas, I have no hesitation in saying that a
Higginson's syringe is quite the best apparatus. Various
tubes are recommended for the purpose, and used at diffei*ent
hospitals.
Under all circumstances, and whatever appliance you
may be using, take care that the part to be introduced into
the rectum is thoroughly well oiled. It is inexcusable for a
nurse to forget or lazily to neglect this, and I have heard
with regret that there are nurses who are either so careless
that they do not take the trouble or are so ignorant that
they have not learnt the necessity of it. Please remember
that this is a rule without an exception. On no account
whatever must any force be used in introducing the mouth-
piece into the rectum, even if any obstruction exists. The
enema tube should not be introduced more than two or two
and a half iiiches. In giving an enema a nurse should have
at hand, in addition to the materials used for the enema,
some utensil and cover in readiness, and a towel. The
patient should, whenever possible, lie on the left side, near
the edge of the bed, with the knees drawn up.
Lect VIII.] XECTURES ON NUBSIXG. 157
In removing the syringe, take care not to soil the sheet
^vith some of the contents, and promptly roll the towel up, and
press it against the patient to assist in retaining the enema
for a few minntes, and this little attention is particularly
necessary with children. Of course, if the fluid is permitted
to return at once, it is likely to do so without producing
a satisfactory result.
Dr. Smith states, in his very useful " Lectures on
Nursing," that the temperature of the injection should be
about 85* Fahr. Miss Wood says, in her "Handbook of
Nursing," from 96° to 100" Fahr. The latter is a higher
temperature than is usually given, and at any I'ate be very
careful never to exceed that. I have heard of disastrous
results ensuing from a nurse administering an enema hotter
than it could safely be given.
Enemas to check diarrhoea are made of starch, usually
with the addition of ten or twenty drops of laudanum,
according to orders. Dr. Smith considers that starch enemas
should be given at a temperature of 100° Fahr. ; but that is a
higher temperature than is recommended by most, and you
will find in the majority of cases it is usual to administer
starch enemas very cool indeed. I dare say most of you know
that neai'ly all remedies for diarrhoea are given cold. The
quantity should not exceed from one to two and a half ounces,
unless special orders are given. As you will probably make
rather more than the quantity you mean to give, take care to
measure out the exact amount before adding the laudanum,
' otherwise'a portion of it will be wasted, and the patient will
not have the benefit of the full dose ordered.
Once more I must repeat my warning in reference to the
effect of opium on children, and impress upon you the
necessity for exti'eme caution when it is ordered for them.
For children starch enemas are frequently ordered without
any laudanum, or in very small quantities ; but I am anxious
158 LECTURES ON NURSING. [Lect. YIII,
that you should realize the imporfcance of the strictest ad^
herence to orders, in this matter especially, both with regard
to time and quantity.
Starch enemas must be administered very slowly and
gently, with a view to causing as little disturbance as
possible. External pressure with the towel in the way I
have just described will sometimes be of great assistance
to the patient in retaining them, especially with children.
In many books you will find instructions to prepare starch
enemas with cold water, and, of course, when any doctors for
whom you are nursing prefer having them made in that way,
you will obediently carry out their orders. Otherwise you
will find that starch enemas made with boiling water are
more effectual, and this is the method given in the British
Pharmacopoeia. The preparation must then be allowed to cool
down to the required temperature, and in some cases that
will be quite cold.
The best appliance for giving starch enemas is a glass
syringe. It is infinitely superior to the ball syringe, for
several reasons. You can see that no air is being given, either
before or after the mixture you are injecting; you can judge
more accurately how much has been given, if the patient
cannot receive it all, and there is no risk of the fluid being
drawn back into the tube again, as is sometimes the case with
the ball syringe. You also avoid the waste consequent upon
putting a small quantity of a somewhat sticky compound into
au unnecessarily large space.
It is also a very neat and clean arrangement. The part
introduced into the rectum must, of course, be oiled, and care
taken to hold the glass syringe firmly in the left hand, that
in slowly pressing the piston down with the right hand all
pressure on or against the patient may be avoided.
The ball syringe can also be employed in conjunction with
a good-sized gum elastic catheter (No. 12), and a small piece
Lect. VIII] lectures ON NURSING. 159
of tabing, with very efficient results. In this case the catheter,
after being well oiled, should be passed up the rectum, which
can be done to a further extent than would ever be safe with
the nozzle of any enema syringe ; the short piece of tube
attached to the other end of the catheter must then be joined
to the nozzle of the ball syringe. The enema, having been
carefully measured, can then be carefully and slowly injected,
and all risk of its being drawn back into the ball syringe can
be obviated by pressing the tube firmly with the fingers, and
by pausing for a minute after all has been injected. The
ball sj'iingo can be gently detached before the catheter is
removed.
Nutrient enemas are best given with the same appliance,
and in the same slow, gentle way. The quantity should not
exceed three ounces, and the object in both cases is to get the
injection to be retained.
, Eggs, strong beef-tea, usually peptonized, cream, with
sometimes brandy and laudanum, according to orders, are
the materials found best for the purpose, the object being to
concentrate as much nourishment as possible into the smallest
compass. They are more likely to be retained if the beef-tea
is slightly thickened with a little arrowroot or starch.
Before administering nutrient enemas the nurse should
ascertain that the bowel is ready to receive them, and not
loaded with faeces. Nutrient enemas are usually ordered to
be repeated at intervals, and there is no reason against making
more than enough for one, at one time, provided you do not
allow the mixture to get sour.
I think this concludes all I have to say to you in reference
to a nurse's duty in connection with the administration of
drugs.
160 ^ XEOTUKES ON NURSING. [Lect. IX.
LECTURE IX.
I HAVE frequently told you that careful, accurate observation
is a very important part of a nurse's duty, and that tlie
knowledge of how to use and cultivate that faculty is an
essential part of a nurse's training. Doctors are often the
first to admit the great assistance which you can be to them
in this way, partly from the greater opportunity which being
in constant attendance upon the patient gives you, and partly
because women are universally acknowledged to have, for
the most part, a natural gift for minute observation of detail
which especially fits them for this office. Men frequently
overlook what a woman of quite average intelligence will not
fail to notice. You may decide for yourselves whether the
masculine mind is too great for the reception of trifles, or
whether it simply lacks this gift of quick perception, and
leaves women in the superior possession of this quality ! At
any rate, you must have the faculty, if you are ever to make
nurses ; and now we will consider how you are to train and
use it.
First, then, you observe for the purpose of reporting with
absolute accuracy whatever may have taken place between
the doctor's visits. Now for this reporting, remember, as the
golden rule for your guidance, that it is your business to
"state facts, not opinions." You must not enlarge upon
what you have to say, and give long explanations. If you
give the facts, fully, clearly, and concisely, the doctor can draw
Lkct. IX.] LECTURES ON NURSING. ICl
his own conclusions, and it is not youv business to dx'avv them
foi' him, nor to state what your conclusious are. Be careful
never to give an opinion unless you are asked for it, and even
if you are under the impression that other treatment would
be better, or would have been ti-ied by another doctor, it is
not for you to show that you think this either by word or
manner. Be very careful in your manner of speaking of the
doctors before the patients, and never give them your opinion
of their case as distinct from the doctors'. You must not be
afraid to speak, if it is your business to answer the doctor,
and so fail to give a truthful impression of what has taken
place. On the other hand, you need not fear exceeding your
duty if you keep to this rule of stating facts only.
Of course, if the doctor has been summoned for any urgent
symptoms, you will state at once for what he has been fetched.
If it is a regular visit, you will wait and first answer his
questions, and give as much information as you can in answer
to his questions, and after that inform him briefly and clearly
of everything else he ought to know. So much for the
manner in which you are to make use of your observation.
Now, in what way are you to observe ?
You must learn to observe on a system, not in a haphazard
sort of way. You must remember that hospitals are especially
places for the observation of disease. It is in these institu-
tions that medical knowledge is made, so to speak. The
patients are placed under favourable conditions for those
skilled in such matters to be able to trace the course of
disease and the effect of remedies in a manner that can
scarcely be done to the same advantage under any other
circumstances. Therefore, if you are an experienced observer,
and a perfectly accurate and truthful reporter, you do not
need me to point out the use that it is in your power to be.
Nurses should use their senses in due order, and mentally
record what these senses teach them. Sight, touch, smell,
162 LECTURES ON NURSING. [Lect. IX.
heai'ing, have all to be trained to do their duty from a
nursing point of view. Experience will teach you the
extreme value of all of them. Every careful night nurse
will tell you how quickly she can detect a change — in the
breathing of any of her patients, for instance ; and I need
scarcely point out of what vital importance the quick obser-
vation of such changes may be. Doctors aid these senses with
the microscope, the clinical thermometer, the stethoscope, and
many other appliances ; but, of course, nurses can ascertain
all that it comes within their province to know, without the
aid of these things.
When patients enter the ward you will notice the way
they toalh or move, whether it is with difficulty, or easily ;
the extent of their helplessness, if it exists ; their colotcr and
general complexio7i, whether livid or pallid ; the pupils of their
eyes, whether they are contracted or dilated, whether they are
of the same size ; whether there are any injuries, and of what
nature they appear to be ; whether they complain of pain,
and exactly where it is, and remember to quote the patient's
exact words in describing pain ; whether the breathing is of
a normal character, or of what character it is ; whether the
patient swallows without difficulty ; whether and exactly how
long the patient sleeps, the kind of sleep, whether restless,
heavy, or light ; whether the motions and urine are passed in
a natural manner, or unconsciously, and of what character
these are ; whether there are any twitchings or convulsions,
and also as to the patient's mental condition, whether he is
tranquil and apparently comfortable, whether he is indifferent
to his surroundings or unconscious of them ; whether in
a state of stupor, of wandering, of quiet or active delirium.
You will not need to comment upon all these points, but you
should always notice them, in addition, of course, to the
special symptoms of the disease from which he is said to be
suffering. I should recommend you to practise the habit of
Lect. IX.] LECTURES ON NURSING. 163
getting tliese points into yonr mind about general cases
where the information is not specially necessary. The habit
will be invaluable to youi'self always, and often of service to
your patient.
You can ascertain by your sense of touch the comparative
heat and cold of your patient. You will know whether the
skin is dry and burning, whether it is moist and hot, whether
it is cold and clammy, whether it is cool, or warm and com-
fortable. ^Notice whether the feet and hands are cold or hot.
You can ascertain the actual temperature of the body exactly
by the careful use of the clinical thermometer. I say
"careful" use, for temperatures taken in the careless way
I have seen them done, are worse than none. A wrong or
doubtful temperature is more misleading than no i-ecord
at all.
Many doctors are reluctant to admit that nurses are
capable of taking the temperature of the patient ; some are
unjust enough to say that they never " trust a nui-se's
temperature ; " but though this is a sweeping and probably
an inaccurate statement, I must say that nurses are in a
great measure to blame for the unsatisfactory impression
which sometimes prevails on the subject.
Since clinical thermometers have come into such general
use the Fahrenheit scale of measurement is almost entirely in
use in England, so we will confine our attention to that.
The normal temperature of the surface of the body in
health is marked on Fahrenheit thermometers at 984°, but
there is also a difference of normal temperature in equally
healthy individuals, so the extremes of temperature in health
may be said to be from 97° to 99-6°. In health the tempera-
ture varies according to the time. It is normally lowest at
two or three a.m., and highest about four p.m. It is most
important to observe the greatest punctuality in taking
temperature at fixed hours.
164 LECTURES ON NUKSING. [Ltxt. IX.
Doctors vary in their preference as to where the tem-
perature shall be taken. Some prefer the axilla, others
the mouth, and for children the rectum, and for some
obstetric cases, orders are given for it to be taken in the
vagina.
You must remember that the surface temperature averages
one degree lower than the others, so you must not take it some-
times in one place and then in another, because that would be
misleading as to the actual variation that had taken place.
If, for any good reason, you are obliged to make the change,
always note the fact distinctly. There is a little care neces-
sary for getting a true temperature in the axilla, not only in
noticing that the axilla is quite dry, and in removing any
clothes from contact with the bulb of the thermometer, but
in placing it so that the bulb is surrounded by and actually
touching the body. It will not do this (as any of you can
easily see if you try it on yourselves) by simply putting the
arm under which you have placed the thermometer down by
the side. You must bring it as far as possible across the
body in front, and if you can make the patient hold the elbow
of that arm in that position you will ensure an accurate
result. Never let patients put in the clinical thermometer or
take it out for themselves. I am afraid, or rather, I Jcnoiv
that there are nurses who do permit patients to do both.
How can you be sure that the thennometer has been properly
placed if you let them put it in, and how can you be positive
that it has not slipped if you do not take it out ?
I have spoken to you before about the importance of being
very faithful over little things. I do not say that you wall
never have your temperatures doubted if they are carefully
taken, but it rests with you never to have any doubt your-
selves as to the perfect truth of the temperature you have
ascertained. Every nurse who proves herself untrustworthy
in these points not only creates a want of confidence in her-
Lect. IX.] LECTURES ON NURSING. l65
self, but does barm to nurses generally, for often people do
not pause to particularize when they have grounds on which
to base a general statement.
A temperature taken in the axilla in the manner I have
described can be accurately ascertained in five minutes, but
eight or tea minutes is the time usually preferred.
In taking the temperature in the mouth the bulb of
the thermometer must be placed under the tongue, and the
patient instructed to keep the lips closed. Of course if the
patient opens his lips and lets in the cold air you will not get
the right temperature. You must also take care that the
thermometer is placed under the tongue and not over it,
otherwise closing the lips will not ensure the true tempera-
ture, because the cold air drawn in through the nostrils will
come straight down on to the thermometer, and so prevent
the mercury rising, or, at any rate, prevent its registering the
true temperature of the patient. You may place the ther-
mometer at the back of cheek or gums, if desired, instead of
under the tongue. Three minutes is long enough to obtain
a true temperature in the mouth, rectum, or vagina. I need
not give you further particulars as to the manner of taking it
in the last-named localities except to remind you to oil the
thermometer.
Certain diseases have characteristic odours which expe-
rience alone can render familiar to you. Vomiting is a
symptom that a nurse must report and notice. She must
also be extremely careful about saving the vomited matter
' according to orders, and about keeping it covered, particularly
from an infectious case. You can only learn from careful
obsei^ation and experience in the wards, the character of
motions, but yon must always notice the colour, whether they
are formed, solid, or liquid, whether they contain undigested
food, worms, any streaks of blood or pus. If you observe
anything abnormal you should always save them for some
166 LECTURES ON NURSING. [LtCT. IX.
one more experienced than yourself to see, whether you have
had orders to that effect or not. Be most particular about
saving motions when you have orders to do so. Neglect in
this respect is thoughtless and inefficient. You must always
be able to inform the doctor whether the patient's bowels
have acted, and how many times.
You will frequently have to save specimens of urine for
testing, as most of you know. You must be scrupulously
careful as to the cleanliness of the vessel into which the
urine is passed, and in which it is saved for inspection. It
should be kept covered to prevent dust getting into it. If
you notice anything abnormal you should save it for the
sister to see, even if you have had no special instructions to
do so. The dark inky appearance indicating that it contains
carbolic acid may be passed over unknoAvn if a nurse, w^ho
may be the only one who has a chance of noticing it, is care-
less enough to throw it away. It may be interesting to you
to know as broad facts that urine passed after taking food is
the most acid, and that while digestion is going on it becomes
almost alkaline. With animal diet there is less acidity, with
vegetable diet there is an excess of acid.
Acid urine turns hlue litmus paper red; alkaline urine
turns red litmus paper hlue.
The normal quantity of urine passed in twenty-four hours
is about fifty ounces. Nurses are frequently required to
measure the quantity of urine passed in the twenty-four
hours, and to take the specific gravity, so you should all avail
yourselves of the first opportunity of becoming acquainted
with the use of the urinometer. You must remember that
this measurement in the same way as degrees on the ther-
mometel', is a purely arbitrary statement. It has been
settled that the specific gravity of water should be measured
by a, definite figure of 1000, and that this should be taken as
the starting-point, so to speak ; and with this acknowledged
Leot. IX.] LECTURES dN NURSINCl. l67
this scale of measurement conveys a definite and universally
the same idea.
The specific gravity of healthy urine varies from 1015 to
1025. Below 1015, albumen is usually looked for ; above
1025, sugar.
In certain circumstances the urine may contain albumen,
sugar, bile, blood, and pus, and other substances, and it will
be interesting to you by-and-by to know what are the different
tests for ascertaining whether, and in what proportion, the
urine contains either of these things. But I must leave this
to be explained to you later on, and content myself with
merely drawing your attention to the fact.
Nurses must notice also if there is anything abnormal in
the manner in which the urine is passed ; if there is retention
or any pain and difficulty ; if with stoppages at intervals, as
frequently happens with "stone cases;" if there is incontinence
of urine. Most of you knoAv enough physiology to under-
stand that the lungs, the skin, and the kidneys are the three
chief means by which impurities are removed from the
system, and, therefore, that any defective action on the part
of one or other of these organs throws additional labour on the
others, consequently you can quite realize the importance of
attending to any of these symptoms.
You will be expected to give an account of the patients'
appetite — whether they take their food at all, whether eagerly
or reluctantly, whether they retain it, and how much ; whether
they are thirsty, whether they complain of nausea, or whether
they actually vomit. Then you must be very particular to
get into the habit of speaking definitely as to quantity, and.
to be as nearly accurate as you can. Do not say " this
patient took a good dinner ; " " this patient has not eaten
much," but try to say exactly, or as nearly as you can guess,
what he actually has taken by weight. For instance, so
many ounces of meat or fish, so many ounces of bread or
168 LECTURES ON NURSING. [Lect. tX.
potatoes, so many ounces or pints of liquid in such and
such a time. Those are facts, and will be concise information
for the doctor's benefit, whereas the vague statements so
frequently given are of comparatively little use.
As different sorts of food are needed by us to supply vai'ious
physiological requirements, there is a distinct object in helping
the doctor with clear infonnation as to what has or has not
been taken. Without attempting to enter fully into that
subject, that will be brought in detail before you in the final
course of lectures, we may just .pause to think what an
important part of a nurse's duty the efficient administration
of food is. Food is absolutely essential to keep the body
going in a condition of health. It is needed to keep up heat,
muscular and brain power. If a person is starved, he loses
weight, vitality, the capability of doing work, physical or
mental, and the temperature falls. The body kept without
food is in somewhat the same condition as a fire kept with a
scanty supply of fuel.
Now, when people are ill, food is even moi'e essential;
but it is necessary that the nourishment be supplied to
them in such a form as to render it of use to them in the
condition in which they are. It must be both digestible and
nutritious. Food to be of use must be brought into such a
condition that it can be absorbed into the blood, that is,
'* digested." When the body is weak and ill, food in a form
that could be taken in health is of no service, because it cannot
be used. For instance, there are conditions in which a solid
piece of meat would wholly fail to convey nourishment, and
be worse than useless for that purpose ; but if the nutrition it
contains be used in the form of beef tea, it will be of service,
because it will not only be nutritious, but digestible, i.e.
brought into such a condition that it could be absorbed by
the blood. Food, to be nutritious, must be digestible ; but all
things that arc digestible are not nutritious. The object of
tECT. IX.] LECTURES ON NURSING. 169
cooking is to increase the digestibility of substances. Some-
times, as we well know, this object is defeated by the ignorant
and inefficient manner in which cooking is done. Of conrse
without cooking it would be impossible to get nourishment
of many kinds into a convenient form for administration,
such as mutton broth, beef tea, etc. Cooking also changes
^the condition of food ; in a raw or cooked potato, for instance,
there is a difference both in nutrition and digestibility.
Then, not only the form, but the kind of food is of great
importance under the varied conditions of disease.
You can readily understand that an alteration of diet or a
refusal to alter it may be based on reasons that you cannot
always see or follow, and consequently trained nurses must be
slow to attribute to caprice any little incidents of the kind
which may come under their notice. There is great scope for
your skill and ingenuity in the way of preparing and ad-
ministering diet. When you have the diet ordered, much
depends upon you as to whether it is taken by the patient or
not. Exquisite cleanliness ; no dripping from the glass, cup,
or spoon, as the case may be; nothing spilt in the saucer;
bringing it fresh to the patient, and not leaving it for him to
see and smell until he turns against it altogether ; taking care
that, if it is intended to be served hot, it is hot, and not luke-
warm ; not running ofE to fetch a knife or fork, or some other
trifle that you ought to have thought of, such as salt, for
instance, when the patient is waiting. All these are points
which depend upon you, and your failure in any of these
details may be the sole cause for the patient refusing what
otherwise he might have been persuaded to take.
Punctuality in administering nourishment of every kind is
most impoi'tant. You should ascertain the doctor's wishes on
the subject of waking your patient to give him food. In
some cases patients would sink from exhaustion if allowed to
sleep on without it, and for others undisturbed sleep is of
itO LECTUEES ON NURSliJG. [Lect. IX.
infinitely gTcater service. Patients frequently sleep better
after taking nourishment. A draught of warm milk or beef
tea will sometimes soothe patients off to sleep when they have
been wakeful for hours. A quiet, skilful nurse, that a patient
has grown to feel a restful confidence in, will often be able to
rouse her- patient snfiiciently for him to drink the required
nourishment without completely waking him up, and this is
one of the many occasions on which a gentle manner and
quiet movements are such invaluable qualifications for a
nurse.
This is the best system on which to observe, from a
nursing point of view, that I can recommend to you. Now
that I have put it before you, I can only hope that yon will
all make it your business to carefully cultivate this habit of
intelligent observation in yourselves.
There is one other subject that I must not pass over
without comment in these lectures. I mean the last duty
which falls to a nurse's share when the life of her patient is
over. It is a sad, and often a very disagreeable task, and it
needs all the refinement and reverence of which you are
capable to do it as it should be done. It is the one thing that
each one of us will inevitably need done for ourselves, and let
us take care that we do, in each instance, as we would be
done by in this respect. The less talking that there is of any
kind the better ; and loud, noisy talking there must be none.
Remember the impression any coarse, unfeeling, or frivolous
remarks must make upon the other patients ; and, while you
must endeavour to be quite bright and cheerful with them,
and not let the sad occurrence in an adjoining bed depress
your other patients or throw a gloom over the ward, there
is all the difference between that and letting them feel that
you ate " hardened " to it. Do not forget what keen observers
and judges of character many of your patients are. Do
not hurry unnecessarily. Some of you, w^ho arc witnessing
Lect. IX.] LECTURES ON NURSlKG. l7l
death-beds for the first time, have probably been startled by
a sudden expiration of air from the lungs some time after all
breathing has ceased, though this does not always occur.
When all is over, the body should be laid flat, pillow and
clothes removed, the limbs straightened ; the jaw should
be tied up by a bandage, with a slit made to take in the
chin, in order to affoi'd tf rm support, and place the mouth
in as lifelike a manner as possible; and this should not
be removed until sufficient time has elapsed to ensure its
being firmly set. Take great care that the eyes are firmly
closed. They will often remain so if you keep your fingers
on the lids a minute or two ; but if there is any further
difficulty, a pad of wet lint, pressed firmly across, will
generally accomplish it, or two-shilling pieces, though that is
not quite so nice. It gives a most distressing and ghastly
appearance if this point is not carefully attended to. It is
best, if possible, to remove the garments immediately before
any stiffening sets in ; but it is not always possible to do this
if the friends are near, and you must be guided by circum-
stances.
After leaving the body for a little Avhile, usually about an
hour, it must be washed. Keep it as decently covered during
this process, as though it were conscious the while ; close the
orifices with cotton wool, if the nature of the illness renders it
necessary — you know there is often a great deal of discharge
after death ; put on a night-dress — it is more convenient if
it fastens down the back ; and lastly, if sufficient time has
elapsed, remove the bandage from the face and arrange the
hair smoothly. For the sake of the mourners you should
make the face look as much as possible as it did in life ; if
there are any wounds let them be bandaged up with cotton
wool or lint. In some hospitals the bandage is not removed
from the head and face until after the body is taken from
the wards. When the men come to fetch it awav, a nurse
i'?2 LECTURES ON NURSING. [Lect. IX.
sliould always stay by to assist tliem, wlietlier there is any-
tking actually foi' her to do or not.
Most earnestly I implore you not to allow yourselves to
forget the solemnity of the office which you are called upon
to perform — one death, two deaths, in a night or day, is the
business-like and not unnatural way of speaking of the heavy
amount of work which occasionally*falls to your share ; but
do not let familiarity induce or excuse irreverence. Probably
your hands are giving the last touches to those that have
been dearly loved by some one no longer near — then treat
their dead as you would have yours treated if it were not
your privilege to be near them. And if it is a sadder case
still, where no friends exist, where it is difficult to believe
that any one ever can have loved the poor degraded man or
woman whose miserable life of sin has closed in utter lone-
liness in the wards of a hospital, surely you will be pitiful
and courteous in every touch, remembering the promise,
" Whatsoever thing thou doest, to the least of mine and
lowest, that thou doest unto Me ; " * and that thought, too, will
help you to bear patiently and without complaint the most
revolting physical part of your task. It does call for self-
denial ; all I would ask of you is to exercise this self-denial
freely. You will not forget that of old this work of showing
reverence to the dead fell much to the share of women, and
in endeavouring to overcome your very natural horror of
some of these details, would it not be well for you to reflect
that this piece of your work demands all the delicacy and
womanliness which you possess, or which you can possibly
cultivate? I confess that I sometimes tremble for the
deteriorating and hardening effect which the frequent repeti-
tion of these scenes of sorrow and suffering has a tendency to
pi'oduce upon you, particularly upon the youngest and most
thoughtless of you ; but do let me urge upon you who are
* Longfellow's " Legend Beautiful."
Lect. IX.] LECTURES ON NURSING, 173
beginning, now while I have the opportunity, to be on jour
guard against this influence, and never let yourselves tend
upon a death-bed, or be in the presence of the dead either in
the hospital or elsewhere, without recognizing " that the place
whereon thou standest is holy ground."
If you do this you will find, as life goes on, your character
will sti-engthen, your sympathies will deepen with your fuller
experience, and instead of growing harder and narrower and
untouched with the feeling of others' infirmities, you will
have the blessing of realizing that it has been very good for
A'ou to be thei'e.
174 LECTURES ON NURSING. [Lect. X.
LECTURE X.
I SHOULD not consider these lectures complete, even in the
very limited sense in which I intend them to be so, without
devoting one to the subject of sick children. The nursing
of children is a speciality, and requires special ti'aining and
study. It needs infinitely more knowledge, more skill, more
observation, and more patience to become a really good
children's nurse, than it does to attain an avei-age amount of
efficiency as a nui-se for adult patients. Indeed a moment's
reflection will serve to convince you of this, if yon have not
fully realized it before.
It is essential for you to recognize the enormous difference
that exists between the characters and dispositions of adults
and of children. You will remember the familiar words,
" When I was a child, I spake as a child, I understood as a
child, I thought as a child." This statement is true of each
one of us, and, in one sense at any rate, it is true that we have
now "put away childish things."
When you enter a children's ward, you encounter a world
in itself, of which the inhabitants are "little people," with
different language, different manners, different feelings,
different thoughts ; and to nurse these little patients well it
is necessary to understand them. Before you can do this you
will have to study them very carefully. You all know the
difficulty of nursing some of the poor foreigners that are
brought to us. " It is so awkward," you naturally exclaim ;
Lect. X.] LECTURES ON NURSING. 175
"bo doesu't speak one word of English, and I canaot half
make out what he wants." But the case of the_ little ones
with a nurse who is ignorant of their ways is even more dis-
tressing, for the reasoning power of an adult at least places
more means at their command of conveying their ideas to you,
whereas the children under such circumstances are helpless
indeed. Many of you are familiar with the following quota-
tion from George Eliot's writing : — " Children, like the birds
and beasts, have often an overflowing abundance of language,
but it is language which is wholly inadequate to express the
blind longings and aspirations, the wounded ambitions, the
moral perplexities, the hungry craving for boundless love,
with which many a sensitive child is burdened. In this
deepest sense childhood is always more or less dumb, even
when most noisy and talkative. He Avho would understand a
child must not only listen for his words, which indeed are
often somewhat futile, but must learn to read the unwritten
speech of eyes and hands, and feel and watch with observant
sjonpathy, not only the tears and smiles, but the gay caresses
and appealing gestures and quick blushes, which it is possible
to ignore or misinterpret."
There are many reasons why you should all endeavour to
become very " understanding " in your dealings with children
— besides the desire to become proficient in every branch
of your profession, with which I trust you are all animated.
Many of you who perhaps feel but slight interest in chil-
dren now, will probably be mothers yourselves by-and-by,
and then how thankful you will be for the knowledge that
you now have such splendid opportunities for acquiring. In
short, few women can go through life without finding them-
selves in circumstances which make theux bitterly deplore
their ignorance of the ways and needs of children, or deeply
grateful for every item of knowledge which they may possess
concerning them.
176 LECTURES ON NUESING. [Lect. X.
Maternal instincts are very real, very true, very beautiful
— I would not say one word that could be interpreted slight-
ino-ly of them — but you may be very sure that they will not
supply or take the place of definite information concerning
the proper treatment of children ; one day or night in the
children's ward would suflBce to convince you of this. How
many out of the whole number of cases in the wards at any
one time have been qualified for admission by the lamentable
ignorance, not to speak of the neglect, of those to Avhom they
belong ? If you take a newspaper and make a casual calcu-
lation, you will see that in the monthly average of deaths half
of those that die are children under five — one-half of the
whole total. Imagine what a terrible proportion ! Again, it
has been calculated that one child in every five dies within a
year of its birth, and that one child in every three dies before
the age of five. These are sad and serious facts, and I want
you to recognize their importance, for it is the plain duty of
women, and therefore still more of nurses, to interest them-
selves in all that concerns the welfare of children. To you is
entrusted the task of guarding the lives of the little ones from
the beginning, and you who are constantly coming in contact
with such pitiable little specimens of humanity, scarcely need
me to point out to you the disease and suffering and misery
which may result from ignorant or neglectful treatment in
childhood, and the ruined lives of those men and women who
have been the unhappy victims of such neglect,
Now, children differ markedly from adults in their physio-
logical condition. They are groiving, and that means a great
deal. Their course of life and growth may be, and often is,
interfered with by external circumstances, and imperfections
of various kinds are set up in the growing child which cannot
afterwards be remedied. This is mainly the case with the
imperfect diet so frequently given in infancy and childhood.
The bent legs so often occurring in children, from the weight
Lect. X.] LECTURES ON NURSING; 177
of tbc body being too great for the legs to support it, is
another fact incidental to the growing condition of the patient.
An adult, however disproportionate the weight of his body
might be, would not get bowed legs in consequence.
It is also notcAvorthy that the vitality of children is greater.
They often can resist injuinous influences that would be fatal
to an old person, though, of course, there are certain diseases
especially chai-acteristic of infancy and childhood. Diseases
in children run extremely rapid courses, and in many cases
you Avill find that the child has either improved or passed
away in an almost incredibly short space of time. On the
one hand you will notice that they struggle through illnesses
that would apparently be fatal to an adult, and on the other
hand you will observe that the thread which binds a child to
life is very slender, and will break almost before yon have
time to realize that there is any danger of it.
Now, if we admit that the organs of children are in a
distinctly different physiological condition from those of
adults, it is not difficult to understand why nourishment
must be supplied to them in such a form as to enable them
to make use of it. I have already told you that all food, to
be nutritious, must be digestible ; and it follows, therefore,
that we have to take gi-eat pains with the diet of children to
ensure its being of such a kind and administered in such
a form as can conveniently be disposed of by the child's
digestive organs. Injudicious feeding is the cause of a large
proportion of the diseases of infants. Deplorable ignorance
prevails, more especially among the mothers in the class of
life from which most of our patients come, as to the kind,
the quantity, and the regularity of the feeding necessary for
them.
Children should, during the first few weeks of their lives,
be fed about eight or nine times in the twenty-four hours,
and as the child gi'owts to be a few months old this number
N
178 LECTURES ON NURSING. [Lkct. X.
sliould be reduced to about four or five times in the twenty-
four hours, and you should be careful to accustom the child
to take its nourishment regularly. Infants suffer exceedingly
from flatulency, and this suffering is materially increased
either by over-feeding or too frequent feeding, or from keep-
ing it too long without food. I need scarcely point out to you
the folly of supplying a child with food every time it cries,
as some mothers and nurses get into the habit of doing. Pro-
bably the baby is crying from pain which a fresh quantity of
food may only increase, whereas gentle rubbing of the child's
abdomen Avould frequently soothe the little creature, and
help to dispel its constant source of discomfoi't, wind. Of
course children do cry because they are hungry — ci-ying is
their chief means of making their wants known — but it is
absurd to imagine that children are always hungry because
they cry.
If you have to bring up an infant " by hand," as it is
called, you may like to know that the quantity of milk con-
sidered desirable is, for the second day, about a quarter of
a pint. The first day it scarcely takes anything. By " day "
I mean in this case the twenty-four hours. The third day
it takes about two-thirds of a pint, the fourth and fifth
day about one pint, and from this it gradually inci-eases, so
that by the time the child is six months old it is usually
taking about two pints of milk in the twenty- four hours.
Cow's milk, diluted with one-thii-d of water, is usually
suitable ; but there is no universal law on the subject. You
must note whether the milk you are giving seems too heavy
for the child in question. It may be that if you mix it with
equal parts of barley water and slightly sweeten it, the child
will be able to digest it readily, or by adding more water
than usual, or some lime water, may possibly be the best
means of adapting the food to the i-equirements of any par-
ticular child. Sometimes cow's milk does not do at all, and
Leot. X.] LECTUKES ON NURSING. 179
then other kiuds must be tried. The condensed Swiss milk
diluted with two-thirds of water is generally found very
satisfactory. There are innumerable " foods for infants "
i-ecommended and sold in all directions, but the drawback in
nearly every one of them is that they contain starch — a
material that very young children are physiologically unable
to digest, so that these foods arc not only useless, but, in
different degrees, positively haroiful to the little creatures
who are the unhappy victims of your ignorance if you insist
upon feeding them with ifc.
The appearance of the first teeth is nature's indication
that other food besides milk may be given with advantage-^
boiled bread beaten up in the milk, Robb's biscuits, and
possibly by this time a little ai-rowroot may be given. Bu.t
remember, these additions must be introduced very slowly
and in very small quantities. Do not forget that the fact of
a child taking w^hat you give it is not the slightest proof of
its being good for it, as many mothers thoughtlessly imagine.
I wonder how often you and I have heard, in answer to the
doctor's question of " How do you feed it ? " the -well-known
answer, " It has a bit of what we has ourselves," and further
inquiries will elicit the fact that probably a bit of bacon, of
meat or fish, or plum-pudding, for instance, forms a part of
the unwholesome diet cheerfully given by these well-meaning
mothers to the poor little creatures entrusted to their care.
We must not blame them for ignorance which pei-liajis they
have never had a chance of remedying, but if you as nurses
will bear in mind the statement I have just made to you as
to the wholly diffei'ent physiological condition of a young
growing child to that of a full-grown adult, you -will at once
undei'stand how it is that children fed in the manner now
described may be positively starving for the want of the kind
of food that could be digested by them, the sort supplied
being worse than useless for providing nourLshraent to organs
180 LECTURES ON NURSING. [Lect. X.
that are not as yet in a sufficiently developed state to receiA^e
them.
Mothers will understand that they would bo badly
nourished if kept on the sort of food given to infants, even
if supplied in large quantities; and you should endeavour
to make them see that in exactly the same way infants are
starved on the kind of diet which seems satisfactory to them.
Feeding-bottles require constant attention from the nurse,
and whenever possible two should be kept in use for one
child, to be given alternately, and the one not in use, after
careful cleansing, should be kept in clean water until you want
to use it again. The bottle itself can be cleaned like any
other glass without much trouble. A little raw potato chopped
fine, or a little shot shaken up in it occasionally, will clean
and brighten it very effectually ; but it is the india-rubber
part of this feeding apparatus which is a constant source of
difficulty ; it so frequently and quickly becomes sour. If the
child declines its bottle your first thought should always be,
is any part of it sour ? Remember, it must be absolutely
sweet and clean. Do not examine it carelessly, and after
a hurried glance or smell say to yourselves, " There is not
much wrong with it ; it will do for this once." If there is
anything wrong with it, it will not do at all ! The best way
to ensure and maintain a perfectly cleanly condition of this
india-rubber tubing is to remove it from the bottle directly
the infant has finished its meal, and wash it thoroughly before
the food has time to dry on it and become sour. Of the two,
it is easier to prevent its getting into a sour condition than
to get it nice again when it has become sour. Please recol-
lect that this is one of the most important points a nurse
has to attend to in the feeding of infants. Weaning under
ordinary circumstances should take place at the age of nine
months, though there is a great deal of variety on this point,
for many reasons.
Leot. X.] LECTURES ON NURSING. 181
I said that the appearance of the first tooth indicated a
certain stage in the child's development, and it may interest
you to know one or two particulars concerning the teeth.
The first set with which nature supplies us are called
milk teeth, and are twenty in number, ten in each jaw.
The second set, which i-eplace these later on, and are called
permanent teeth, number thjrty-two, sixteen in each jaw,
The fix'st teeth we expect are the two central incisors — usually
these appear in the sixth or seventh month; two lateral
incisors, about the eighth or ninth month; two canines do
not appear until about the eighteenth month ; but two molars
appear from the ninth to the twelfth month, and the other
two molars about the twenty-fourth month.
After five years children generally begin to lose these
teeth, and they are gi^adually replaced by the permanent set.
Most children suffer a good deal during teething, and are
very fretful and restless with the pain. Convulsions are not
infrequently brought on at this period. This is always rather
an anxious time for those Avho have the care of babies ; but
you may remember, as a general rule, though there are
exceptions, that they do not take measles and other diseases
more or less incidental to childhood until after they have
reached their first or second year.
It may be a matter of passing interest to you to know that
the average weight at birth of a male infant is estimated to
be seven pounds eleven ounces ; of a female infant, seven
. pounds four ounces. This reminds me to beg you to be most
careful in weighing such cases as you are instructed to weigh
with every care; accuracy is of great importance to the
doctor.
I have spoken of the feeding of children first, because it is
closely connected with the point of the physiological difference
between a child and an adult, and I am anxious to impress
this fact iipon you ; but I scarcely know if I am right in
182 LECTURES ON NURSING. [ Lect. X.
letting cleanliness take tlie second place. At any rate, let me
beg of you not to regard it as a secondary consideration. I
am not afraid that you will exaggerate the importance of it,,
for that is simply impossible. Not only would many forms
of skin disease be far less x'ife if scrupulous cleanliness were
insisted upon, but no drugs, nor even good feeding and pare
air, can supply the place of it. Children must have clean
bodies if you mean them to be healthy, and, though you may
smile at the notion, I can assure you that keeping them clean
materially assists them to be good. You may always observe
how happy a healthy baby will look after it has been made
clean and comfortable, Avh ether it has enjoyed the washing
process or not, and a great deal depends upon the way the
ablutions arc done as to whether the child takes the per-
formance placidly. Whenever possible, a morning bath,
given at about the same temperature as the child's body, is
very desirable. Let it be rapidly done, and the child
thoi'oughly dried and wrapped up to prevent chill.
Some children are frightened at the mere idea of a bath ;
but this is generally the result of bad management. As a
great part of the good to be derived from a bath would be
prevented by any shock or fright, this should be patiently
guarded against, and the child be gently encouraged to like
it. Occasionally the sight of the water terrifies the child,
and then it is best to cover the bath with a blanket, and let
the child gradually into the water by putting it on the top,
and letting it sink into the bath by degrees. By this means
a timid child will grow half-intei'ested in watching the w^ater
come through the blanket, and be spared all alarm at the
process. It indicates tact and good management on the part
of a nurse when the little children under her charge enjoy
their baths, and I am inclined to think that the contrary
qualities are suggested when the reverse is the case.
However, the sick or injured children, that you have
Lect. X.] LECTURES ON NURSING. 183
mainly to consider, cannot often be treated in this manner,
and so you must wash them thoroughly in bed, though it takes
a little longer, and gives you more trouble. After you have
thoroughly washed and dried their backs, dust them freely
with starch or zinc powder. You cannot take too much
pains to prevent a chafed and abraded skin. And once more
I must take the opportunity of reiterating my warning against
the dirty habit of washing more than one child in the same
water. The idea is sufficiently repugnant in connection with
a healthy person, need I point out to you how much the
objection is intensified in sickness ? I do not for one moment
do you the injustice to suppose that you would deliberately
run a risk of infection to any of the patients entrusted to
you ; but what I do want you to see is that it is your business
to think of and understand these things, and that if harm is
done through ignorance or carelessness on your part, it cannot
be excused on these grounds. A separate towel, separate
flannel or piece of lint, and separate water for each patient
should be a rule without an exception in a children's ward.
I need scarcely point put to you the necessity of changing
draw-sheets and napkins directly they are soiled. It is your
one chance of avoiding sores and of keeping the atmosphere
of your ward fresh and pleasant. It is often difficult, even
when you have done your best, always to have them fit for
the doctor's inspection in this particular. I can only say, do
your best, and always have them as nice as you possibly can
for your own satisfaction.
Many of the children have been badly educated in habits
of cleanliness, and you may do a great deal for them, and
save yourself trouble by judicious management. It is an
excellent plan to place those who are able on the necessary
utensil early in the morning and after each meal. Persevere
with this, even if you do not meet with success at first.
Usually after children wake up from a sleep this need should
184 LECTURES ON NURSING. [Lect. X.
be anticipated. Encourage them to call £ov what they want,
and praise and recognize their little efforts to be good in this
respect. This method will obviate the necessity of scolding,
and be of more service.
Children are very troublesome ; there is no denying the
fact. Their little Avants are endless ; and when you have
many under your care, all crying and wanting things at once,
the most devoted lover of children may be forgiven iov feeling
Avearied and impatient with them, though not, perhaps, for
slioiving it. The self-control which some nurses exhibit under
wonying circumstances is truly admirable, and cannot be too
cordially emulated by others who are anxious to excel with
children.
Keep the body-linen of the children frequently changed
and aired. I have already pointed out the advisability of
changing the night-dresses of those who ai-e living in bed
every night and morning when possible.
It is very troublesome sometimes to keep the splints of
children in a clean condition, especially the padding. There
are so many difficulties in the way. Cover them with oiled
cotton as much as possible, to keep any moisture from soak-
ing through. On the other hand, you have no idea how
rapidly lice generate in splint pads, especially when assisted
by this covering of oiled cotton ; so look out carefully for
them, and be sure and tell the sister at once of the first
suspicion that they have begun. Plaster of Paris splints
and others of that description are best varnished over after
the splint has dried, so as to render them impenetrable to
moisture. A coat of spirit varnish is the best and safest
application you can use. Box splints are quite a comfort to
a nurse in helping to maintain cleanliness, because they enable
her to turn the little patient round on its face, and clean and
relieve the constrained position without risk of too much
movement to the injured limb,
Lect. X.] LECTURES ON NURSING. 185
Tho third essential to the well-being of children, after
suitable diet and cleanliness, is plenty of warmth, light, and
fresh air. Warmth is a necessity for children. If they are
deprived of it to any great extent, they die. It ig, un-
fortunately, no unheard-of thing .for cold to be the active
agent in killing some of the poor neglected little creatures in
our overcrowded cities. A certain amount of external warmth
is essential, and children do not possess sufficient vitality to
dispense with it. I mean that, in proportion, children are
infinitely more sensitive to cold than adults. Acute chest
attacks are far more fatal to children than to grown-up
people.
Then children cannot flourish without light. It is the
want of light and fresh air which stunts their growth, and
has no small share iu producing the pallid little objects with
Avhich our London streets abound. We do not expect the
flowers to grow without sunshine, nor the trees to bring
forth their foliage, neither can the very colours of the insect
be developed without light ; and as we have learnt this from
observation, wo may well take the hint that nature aids us
with, and give the children as much light and sunshine as
there is to be had from the first thing in the morning to the
last thing at night. Children rejoice in light by instinct.
Who, that has noticed a child at all, has not seen how its eyes
will follow a lamp or a candle about, or how it will lie
steadily and blissfully blinking at it ? Poets and moralists
have had a gi'eat deal to say about the child's efforts to grasp
at sunbeams, and most of us have smiled at such a sight.
Perhaps it would be as well for us if we did not grow so very
unobservant of the sunbeams as we grow older. However, I
have said enough for you to know the importance of this
detail. I need not add more than a passing comment upon
the necessity of giving children fi'esh, pure air when they are
asleep, because I have already made you fully aAvare of the
186 LECTURES ON NURSING. [Lect. X.
importance of it; but I mention it as a distinct fact for you
to keep in remembrance.
I shall not say very much to you about the different
diseases of children, becaixse we have already spoken of many
of them under other headings. Tracheotomy is one of the
most anxious cases through which you can nurse a child.
This operation and the nursing of it Ave have already discussed
in detail.
I have also told you of the extreme care necessary in
moving cases of hip disease, but I remind you of it now,
because it is chiefly with children that you have to do with
it. Do be careful to keep the limb perfectly straight when
you raise the child, and the head rather lower, if anything,
than the rest of the body, to prevent any additional weight on
the inflamed joint ; stand on the well side, with the diseased
or injured ]un.h farthest from you. Any jerk is perfect agony
to the unhappy victim of this complaint, so pray be very
carefu.1 not to swing the weights to and fro Avhen you are
dusting the cot, or to knock up against them when you are
hurrying up and down the ward. When you have to move
the cot in which such a patient is, do so slowly and steadily,
not with a sudden push. If the disease is at all advanced,
those upon night duty will find that the patient is apt to wake
up from a deep sleep with a shriek of pain — a cry indeed
which is in itself characteristic of the disease to those who are
familiar with it ; Sometimes they scream thus in their sleep,
but more often they wake up in a fright. This cry is due
to the spasm of the muscle which pulls the two inflamed
surfaces of the diseased joint violently together, causing in-
conceivable agony. Always go to the child, and see that the
weights are all right, and the limb in good position ; and,
above all, never scold it for making a noise, as though it could
help it. Persons suffering from hip disease nearly always
complain of j^ain in the knee, instead of in the hip itself. Yon
Lect. X.] LECTURES ON NURSING. 187
will perhaps wonder that I lay so much stress npon the
nursing of this one class of cases ; but if you had spent as
many nights and days as I have in the wards of the Alexandra
Hip Disease Hospital, and had opportunities of seeing how
very much the suffering of these patients is increased or
diminished exactly in proportion to the ignorance or skill of
the nurse, you would not wonder that I am so earnest in
beseeching you to be tender with these children, and to give
yoiirselves the trouble of learning how to handle them. It is
so pitiful to see a little thing sobbing for half an hour with
the torture it has to endure through the clumsy touch of a
well-meaning person, who, ij she is a nurse, remember, ought
to know better.
Cases of burns and scalds I have already spoken of, and
the careful manner in which they must be undi'essed when
they are carried into the ward — that is, if they are in a con-
dition to be undressed at all. Children, with their sensitive
organization, bear shock very badly, and many, many cases
are fatal fi-om this cause. The various applications used, the
manner of applying them, and the importance of keeping a
burnt or scalded surface covered up from the air, are matters
on which we have pi-eviously spoken.
There are still a few points to which I must call your
attention, but having done that, I must leave you to make
the practical observation which alone can render these hints
of any service for yourselves. Study the faces, the expression,
the colour of sick children.
A celebrated French physician, who had charge of the
hospital for " waifs and strays " in Paris, stated that he
was able to diagnose children's diseases from the lines and
fuiTOAVs on their faces. I tell you this, not for you to do the
same, but to show you Iioav i-eal such indications must be, and
to show you, too, how thoroughly worth while it is for you to
study the signs written so clearly for those who " have eyes
188 LECTURES ON NURSING. [Lect. X.
to see." Witliout entering into tlie more obscure details
whicli follow the statement of this distinguished man, you
may remember this : That with pain in the head you generally
find contraction of the brows; with pain in the chest the
nostrils stand out sharply and work rapidly ; with pain in
the abdomen yon may generally notice a drawing-in of the
upper lip.
There is a good deal to be leai'nt from the colour. Lividity
of the lips and eyelids shows a weak condition of the circula-
tion ; a faint purple tint of the eyelids and round the month
indicates some difficulty in digestion. A general earthy tinge
of the complexion is a sign of chronic bowel complaint. These
are broad general statements which could be multiplied a
hundredfold were it necessary for our purpose.
The cr]i of a sick child varies in a most curious manner,
and conveys mnch information to those skilful in the inter-
pretation of these sounds. In brain disease you get a sharp,
short, sudden cry. If the child is crying from stomach-ache,
the ci-y is more prolonged and wailing ; if a child is hungry,
thirsty, or suffering from ear-ache, it will cry almost without
ceasing, because the cause is constant and does not occur in
paroxysms. If the child is suffering from inflammation of
the chest or windpipe the cry will naturally be hoarse or
whispering. I might describe these signs to any extent, but
I have said enough to show you the many directions in which
you, must seek the valuable amount of information that an
intelligent observer cannot fail to discover.
I have not yet said anything about providing amusement
for children, bnt it will not be wholly disregarded by one of
their special nurses. As a matter of fact children have a
marvellous capacity for amusing themselves, if they are well
enough to be amused at all. You cannot have toys scattered
all over the place when you are expecting the surgeon, of
conrse, and, as a rule, children are xerj amenable to judicious
iiECT. X.] LECTURES ON NURSING. 189
mauagenient, and much influenced by eacli other's example,
cither in the way of being good ox' being naughty. But
while order is good, and neatness indispensable, I should
like to see a little more tact exercised occasionally in the way
of a wise exception to this rule, such as giving a doll, or a
toy, or a book, to a little new child whose grief at finding
itself amongst strangers would be gradually mitigated by
this ari-angement. There have been occasions on which I
have had reason to fear that some of you are not as careful in
soothing the little ones, when they are first brought to us, as
you might be with advantage. We know that they will be
perfectly happy again in an hour's time, but they do not know
that, and it is just that point which makes all the difference.
Children live in the present, they do not look forward or
backward — this is universally a characteristic of childhood.
Tiy and realize this ; it will help you much in your en-
deavours to understand children. Victor Hugo, who has
depicted some of the most tragic scenes which have ever
happened in this world, and painted the miseries that men
and women suffer in powerful colours, says positively that
there is no misery like the misery of children. And this is per-
fectly true, for the joys and sorrows of childhood fill their
whole minds and hearts. They are quite as intense as they
are transient, and I cannot say more than that. Children's
brains, children's ideas, children's thoughts and ways, ai-e not,
as a rule, sufiiciently studied. We do not half, recognize the
straggle that the tiny creature goes through. How it strives
to grasp matters far beyond its reach, and puzzles its little
brains to comprehend what goes on around it, and beyond.
It is a great mistake to suppose that children do not think.
It is true they do not think and reason as we do, but they
understand more than we have any conception of. The faith
and tru.st of childhood is one of the most beautiful things
that wc ever get the chance of seeing. It is our own fault
190 LECTURES ON NURSING. [Lect. X.
if we shut our eyes to it. lu our tuvu ^\c Lave much to
learn from the children. If we could have retained our belief
in truth and the splendid realities of life and nature, as we
felt them in our childhood, do you not think that in many
respects our daily lives would be grander, nobler, and higher
than they are ? and in this sense we should do well to take a
lesson from the little ones and remind ourselves that *' of such
is the kingdom of heaven."
And this brings me to a matter that I must not pass
over in silence — I mean the use that you should make of
having these untaught, uncared-for little ones brought
under your influence from the squalid life of sin and misery
outside our Avails. They come in to be nursed — yes, that
is true, but that is not all. Dozens of these little ones
may never have another chance of learning what it is in your
power to teach them, and that, too, without any extraordinary
expenditure of time and effort on your part. You arc kind
to them, and you have all experienced how readily childx'cn
respond to love, and how sweet it is to see their little faces
brighten up at the sight of you. They tax your patience, but
I think when I sometimes see the contented way in which
these little mortals are nestling themselves in nurses' arms
that you have your reward. What chance have the children
of comprehending what love means when they see no ray of
it penetrating their daily surroundings ? They learn to curse
as soon as they can speak, just as readily as they would learn
to pray if they had had the chance, for children are naturally
imitative. At whose door does the result lie ? Let them
leave the hospital with fresh thoughts in their young minds.
It is your part to sow the seed, and be cheered with the
thouo-ht that good seed cannot fail to bear fruit, though yon
may never see it. You may not only be the means of helping
the child, but that child may have opportunities, which never
could have been at your disposal, of showing light to others.
Lect. X.] LECTURES ON NURSING. 191
George Eliot encourages us with a beautiful thought on this
subject : " In old days there were angels who came and took
men by the hand and led them away from the city of Destruc-
tion. We see no white-winged angels now. But yet men are
led away from thx'eatening destruction ; a hand is put into
theirs which leads them forth gently towards a calm and
bright land, so that they look no more backward ; and the
hand may be a little child's."
In conclusion, then, think no time wasted that is bestowed
upon the children. Be gentle and good to them for their sake
and for your own. It would be a very old, weary world, if
thei'e were no children in it to keep us fresh and hopeful, I
imagine that wc shall all be inclined to admit the truth of
another of George Eliot's wise sayings : " We should never
have loved the earth so well, if we had had no childhood
in it."
i92 LECTURES ON NURSING. [Lect. Xt.
LECTURE XI.
The nursing oE fever cases and questions of infection and
disinfection, as far as these matters come within a nurse's
province, are subjects full of interest to all of us.
You seldom have the nursing of so-called infectious
diseases in a general hospital, as they are very properly re-
moved to institutions set apart for them ; but there is always
the chance that you may have them to attend to. Those of
you who are preparing for private nursing are almost certain
to have a good proportion of them, inasmuch as every one is
more or less liable to be the victim of infection. The import-
ance of your thoroughly understanding all the duties Avhich
fall to a nurse's share in connection with these illnesses is
increased by the fact that in this kind of nursing you have
not only the welfare of your patient to consider, but the
welfare of the public, in preventing the spread of such
diseases, and also you have to guard your own health in
every way possible, without, of course, making the comfort
and wants of your patients a secondaiy consideration.
Those of you who are interested in general questions of
health, apart from the details that come strictly under the
heading of nursing, would do well to get yourselves a cheap
little American book, entitled " Long Life and How to reach
It," by Dr. Joseph Richardson. It contains a great deal of
practical infonnation, conveyed in very simple language, and
amongst other subjects there is a chapter on " contagion.
Lect. XI.] LECTURES ON NtRSlNG. 193
and how to escape it," whicli you miglit all spend ten minutes
profitably in reading. One or two points I shall quote from
it this evening.
Contagion means ''to touch together," and "is the term
applied to the material in consequence of which a healthy
person, touching a diseased one, may have conveyed to him
the disease with which the latter individual is affected. The
word infection is applied to the substance or influence by
which a malady is transmitted from one person to another^
either with or without actual contact."
You will, therefore, understand that whereas all infectious
complaints must be contagious, all contagious complaints are
not necessarily infectious. Numerous and violent are the con-
troversies which have been waged, and are still being carried
on, in regard to the true nature of contagion. Probably there
is no subject on which doctors are more at variance than
this one. But it would be quite out of place for me to speak
to you of any of these varied theories.
We have not to deal with the scientific side of the question ^
absorbingly full of interest as it is ; but the details of putting
into practice such measures as have been accepted as service-
able more or less universally, or such as may be deemed de-
sirable by the particular doctor for whom you may be nursing,
it is our duty as far as possible to understand. It is distinctly
from this point of view that I am anxious to put before you
some definite information to-night. It is a great help to
a nurse to be familiar with general I'ules for her guidance in
any branch of her profession. It may not always be well or
possible to follow them, but if variations from them are the
exception, that does not detract from their value in the
majority of instances. Knowledge is power in everything,
and in the case of trained nurses intrusted with the charge
of patients suffering from diseases ready to spread to in-
numerable victims if you will let it, wliat power the judicious
0
194: LEOTUEES ON NURSING. [Lect. XI,
exercise of this practical knowledge of yours places in your
hands ! One of the greatest blessings we are ever granted
is the opportunity of helping others ; one of the greatest
pleasures is the conviction that we really have been of service,
and this is a pleasure that you as nurses will often in future
be able to secure if you take pains to duly qualify yourselves.
Knowledge of the general laws of health and for the
prevention of the spread of disease cannot be too generally
diffused. Do not lose sight of this fact, for many will be your
opportunities of giving information to those Avho are thank-
fully leaving their friends and relatives during these infectious
illnesses in your more skilful hands. The majority of people
take but passing, if any interest at all in these matters, until
some person they know happens to be the sufferer. Then,
when their personal interest is awakened, they will be eager to
learn all the practical information on the subject that you can
supply them with, and they will naturally look to you for it.
Take care that you have it ready to bestow upon them, other-
wise there will be another means of good left undone through
ignorance.
I have recently been reading rather an interesting lecture
on preventable diseases and their causes, delivered by Dr.
Smart at Edinburgh some two or three years ago. He
describes a preventable disease as " one which arises or
spreads in consequence of the wilful, careless, or ignorant
violation of those laws, the proper observance of which we
know to be necessary to insure the preservation of health
and avert the spread of disease. . . . Accepting, as we do,
the theory that each case of infectious disease originates in
the reception of a distinctly specific, pre-existing poison, and
that it in turn becomes self-propagating, we will first point
out some features which are common to the whole group,
and then speak a little in detail of the distinctive character-
istics of each of these ' zymotic diseases,' as they are usually
Lect. XI.] LECTURES ON NURSING. 195
called. They all begin with a period of what is termed either
'dormancy' or 'latency,' or more genei-ally 'incubation,'
during which the poison is actively developing. But the
duration of this period differs in each disease, and there is
considerable variety in individual cases in each disease.
These differences in the length of the incubation period are
probably due in each instance to the amount and strength of
the poison received.
" These fevers are all ushered in by a marked and some-
times sudden elevation of tempei'ature, which, with variations,
continues during the course of the illness. It is because
of this increased temperature that they are called fevers.
Characteristic eruptions next appear." Unfortunately we have
no remedy that is able either to cure these disorders or to
shorten their duration ; and we ai'e obliged to content our-
selves with placing the patient in the best hygienic condition,
and with treating such complications as may present them-
selves as they arise.
Patients should be confined to bed during the whole
course of the fever, and all bodily and mental exertion must
be strictly prohibited. The room must be maintained at an
equable temperature, not exceeding 60° Fahr., and plenty of
fresh pure air must be admitted to the patient. Free ventila-
tion is of the utmost importance ; and all carpets, curtains,
screens, and other furniture likely to interfere with this must
be removed. The room must, of course, be kept quiet, and
if the patient shows much tendency to mental excitement and
delirium it will be best to darken it.
Patients suffering from fevers may generally partake
freely of liquids, such as water, iced water, to ast-and- water,
barley water, and so on. Many of you may be familiar with
the popular prejudice — which formerly existed to a much
greater extent than it probably does now — against giving
cold water to patients with fever, and gi-eatly must the suffer-
196 LECTURES ON NURSING. [Lect. XL
ing of these nnhappy victiiiis, parched with thirst, have been
increased by this well-meaning but ignorant treatment. I
mention this because it is well for you as nurses to know
that there are no grounds for this prejudice. But remember
that these patients will be eager to drink all they can get,
and you should not put into their hands too large a quantity
at one time and expect them to didnk] a little of it. Put as
much as you intend them to have in the vessel they are to
drink from, and then give them a fresh supply when they
need it. They may have frequent draughts of water, but not
too much at one time ; and with children it is very thought-
less to make them cry by giving them a cup or a feeder full
of water and then to take it away from their eager little
lips when you think they have had enough.
Food cannot pi'operly be digested when fever is running
high, so patients are usually kept without solids, and nouiish-
ment is supplied solely in the form of liquids. But of course
the doctor will order the diet he may prefer for each
individual case.
Another point which nurses can scarcely lay too much
stress upon is the necessity for absolute cleanliness, not only
of the patients' surroundings, but of the patients themselves.
Thex'e is a curious dread of washing and sponging patients
when they are suffering frona these complaints. It is thought
that the rash would be " driven in " if the surface is touched
with water. This popular belief has probably arisen from
a well-founded horror of patients suffering from fever " getting
a chill," and very serious reason there is for extreme care in
guarding against such a possibility. Most of you already
know enough physiology to be able to form some idea of the
exceeding danger of checking the action of the skin at any
time, and this danger would be immensely increased in a
condition of fever. It would result in extra work being
suddenly tbrown upon the kidneys, producing in all pro*
Lect. XI.] LECTURES ON NURSING. 197
bability inflammation of those organs, followed by dropsy and
other gi'ave complications.
But you are well aware, as nurses, that there need not be
the very slightest risk of taking cold either in frequent
sponging or in frequent changes of linen, but that, on the
contrary, the patient will be relieved and benefited by both.
The passage of a damp sponge, not quite cold, unless specially
ordered, is a source of great comfort to a patient whose skin
is dry and burning with fever, and not only of comfort, but
of positive service, as this tends to increase the action of
the skin.
I think this serves to illustrate the value of good nursing.
Here is a remedy and a means of relief which doctors dare not
avail themselves of if they cannot rely upon its being skilfully
administered, and I hope this fact will serve as an inducement
to you to take pains about apparently trifling details. Care-
fully air the bed and body linen, but you need not insist
upon putting it on warm, if it is not agreeable to the patient.
The sensation of the cold linen against their burning limbs
is generally vex*y welcome to any one suffering all the dis-
comforts of a high temperature.
Now let us speak briefly of the conditions under which
infectious diseases are considered to spread.
The generally accepted theory is that infecting germs
may be dispersed in a variety of ways — wafted by the air,
carried by water and milk, or conveyed by our clothes, our
money, or the innumerable commodities given in exchange
for that. There can be little doiibt that in the majority of
cases the spreading of these diseases is brought about by the
healthy coming in contact with the sick or convalescent.
Children after these attacks are allowed to go back to school
long before such a step can be taken with safety to their
companions. Laundresses disseminate the poison amongst
their employers, when the linen from these cases is sent
198 LECTURES ON NURSING. [Lect. XI.
them in an infected state ; and these women, too, have lost
their lives before now from receiving clothes that have come,
impregnated with fever poison, straight from fever patients.
I name this source of infection specially because it is one
with which the nurse has much, or, indeed, everything, to do.
There are numberless other ways by which each of these
fevers can be conveyed, but I need not now dwell upon them
at greater length. We can with more profit turn our attention
to the details that nurses have within their own control.
To begin with, let us take the regulations for nursing
typhoid fever which the physicians of this hospital desired
to have carried out in our wards. I commence with this —
not that typhoid fever is infectious, in anything approaching
the same degree as the other class of fevers, of which we will
speak presently, but because it is the one which you have
unrivalled opportunities for studying here.
Typhoid fever differs from all the others, in its being but
slightly, if at all, infectious through the air ; and it is for this
reason that, with perfect safety to ourselves and the other
patients, we can with certain precautions nurse it freely in
our general wards.
This malady is generated by the contents of sewers and
cesspools, and by the drinking of impure water or milk.
The seat of the attack is the intestines chiefly, and the poison
is mainly eliminated by that channel. It is accordingly the
intestinal discharges that have to be most carefully looked
to, and every precaution must be taken by disinfection and
removal. These discharges acquire their maximum infective
power when decomposing. Now suppose you have a case
already diagnosed typhoid, when it is brought to the ward,
in the first place remember that —
1. Patients' clothes are to be sent to the fumigator as
soon as taken off.
2. All vessels (feeders, cups, jugs, bed-pans, etc.) in use
Lect. XL] LECTURES ON NURSING. 199
for the patient are to be marked and kept entirely for that
pattenfs use.
3. All linen (sheets, shirts, etc.) is to be put into a
metal pail (provided for the purpose) containing cai^bolic
solution (1 to 19). If the linen should be soiled with
evacuations, the pail is to be brought to the bedside, so as to
avoid carrying such linen through the ward, and infecting by
their eflSuvia.
4. Before giving bed-pan or urine-bottle to patient, put
some carbolic solution in it ; and, after use, cleanse with car-
bolic solution. (Bed-pans must always be carried covered.)
6. No discharges from the patient are to be left under
the bed. TThey must be taken away at once, and, if to be
reserved, put (with carbolic solution) into a glass pan in the
lavatory — such pan to be covered.
6. Sprinkle under and round the bed constantly with
carbolic solution.
7. A basin of Avater containing carbolic solution is to be
kept near the patient's bedside, into which the nurses are re-
commended to dip their hands after attending to the patient's
requirements.
8. Cleanse the thermometer in carbolic solution after
each time of using.
I may tell you, though it does not come within your
province to see after it here, that boiling is the surest way
of disinfecting contaminated clothing, or baking in an oven
heated to about 240" Fahr. But remember, if you ever
attempt disinfecting linen by the boiling process, the germs
will only be destroyed by water at boiling point. That kills
them, but any warmth short of that makes them grow ; so be
very careful.
These directions are so clear that I think I need make no
comment upon them, or pause to impress upon you the
importance of conscientiously carrying them out. Any
200 LECTURES ON NURSING. [Lect. XI.
failure of duty on your part may be indirectly, or perhaps
directly, the cause of fatal results to yourself or others, and
I hope this reflection will have due weight with you.
There is one other point that I may as well mention now,
because it is well for a nurse to remember it, in addition to
these, for other fevers, though it is superfluous as a precaution
against typhoid. I mean the desirability of hanging up a
sheet soaked in some disinfecting solution, and particularly
placing one in the form of a curtain over the door that may
lead into uninfected parts of a house.
If the air is impregnated with poisonous germs, it is a
very reasonable theory to load the atmosphere as far as
possible with the antidote to that poison ; and remember that,
if employed at all, the sheet must be kept thoroughly
saturated with the disinfectant, otherwise it will be of no
service. It is for this reason that, when you suspect the
occurrence of an infectious case in the wards, you immediately
surround the bed with clothes wrung out in carbolic acid
solution or some other disinfectant, to prevent the germs that
may be emanating from the patient filling the atmosphere of
the ward. You should also remember to use a damp duster in
the neighbourhood of an infectious case, and not send the
dust, which may be mingled with poisonous germs, flying
about in all directions.
The special characteristic of typhoid fever is ulceration
of a particular portion of the intestines. This is the main
cause of the tenderness of the abdomen on pressure, and this
is the chief reason why you have to keep your patients
absolutely at rest, not allowing them to sit up, and not
allowing them to stand or get out of bed on any pretext
whatever. This also explains why it is a matter of such
vital importance to keep these patients without solid food of
any description. When you conceive the risk of perforation
of the bowel, which may so easily ensue if any hard article of
Lect. XL] LECTURES ON NURSING. 201
diet comes in contact with, or gets deposited on, membranes
in this condition of ulceration, I think you will be more than
ever careful with these patients yourselves, and consider no
trouble wasted in impressing upon them and their friends the
great necessity for enforcing to the letter the doctor's orders
concerning liquid diet.
In typhoid fever the bowels are relaxed, and the motions
of a light ochre colour. Sometimes they may contain blood,
and this is a most important symptom, and must be carefully
watched for.
Frequently a number of rose-coloured spots appear upon
the abdomen and elsewhere, and these vanish on pressure,
and return when the pressure is removed. Each one lasts
about thi-ee days, and then fades insensibly into the hue
of the neighbouring skin, and other spots follow. Sir
Thomas Watson tells us that these spots begin to show them-
selves, generally, during the second week of the disease, and
fresh spots come out every day or two till the third week, in
the course of which they cease to appear, except in cases of
relapse, when they also may recur with the other symptoms.
This eruption of rose-coloured spots in successive crops is
highly diagnostic of typhoid fever. Sir William Jenner
holds that this species of fever is over by the thirtieth day,
since, under ordinary circumstances, no fresh spots are seen
after that day. Of course the illness may continue much
longer, protracted by the effects of the fever, or by pre-
existing local complications. Dr. Murchison states that the
pupils of the eyes are dilated in typhoid fever.
You must be exceedingly cai-eful and accurate in taking
the temperature of these cases. It is a symptom full of interest
to the doctor, and one which may be actively guiding his
treatment. Any sudden drop of temperature must be care-
fully noted, and promptly reported. It may possibly be the
result of drugs given to lower the temperature, or it may be
202 LECTURES ON NUESING. [Lect, XI.
the first Indication of internal hemorrhage or other serious
symptoms. I mention this, as some of you might be apt to
imagine, from the fact that so much attention is paid to
bringing the temperature down, that the decrease must of
necessity be satisfactory. It may be, and, on the other hand,
it may be quite the reverse ; so pay great attention to this
and coi'responding symptoms.
Complete recovery fi-om typhoid can never be announced
till the evening temperature shows perfect freedom from
fever.
Sometimes slight epistaxis, i.e. bleeding fi'om the nose,
occurs in typhoid fever; but it is not a seinous symptom,
unless the bleeding is profuse.
You will, of course, be careful to have the patient placed
on a spring bed, with a hair mattress and light bedding.
The patient must be kept in a recumbent position, but
not lying on the back, as he often has a great inclination to
do. He must be very gently turned partially round from
side to side, and supported in that position by pillows care-
fully arranged for the purpose. This is done partly with a
view to preventing the occurrence of bed-sores, and partly to
obviate the tendency to pneumonia.
Typhoid patients should never be allowed to sit up,
except when it is essential for the doctor to examine them,
and then they must be very carefully raised and supported.
In certain stages of typhoid fever the act of sitting up
suddenly might induce perforation of the bowel, and syncope
— I mean sudden failure of the heart's action — has always to
be guarded against in these cases. The nurse must not forget
to notice the quantity of urine passed by a patient suffering
from typhoid fever, nor fail to report the fact if there has
been any temporary retention.
I think this is all I need say with regard to the general
nursing of typhoid fever. All special treatment you will be
Lect. XL] LECTURES ON NURSING. 203
very careful to carry out intelligently and carefully, and re-
member that each physician Avill have his own view as to the
desirability of bathing, sponging, cradling, and so on, and the
nurse's part is implicit obedience to those views in every case.
Typhus fever is highly infectious, and you are not likely
to see much of it in a general hospital. Nevertheless, it is
desirable that you should be told something about it. It
is said to be " caused by overcrowding and deficient ventila-
tion, and it is very apt to attack those who are exposed to it
for the first time." The poison is thrown off by the skin
and lungs, and readily infects the atmosphere, clothing, and
furniture, so that the chief precautions are those of ventilation
and disinfection.
Sometimes typhus fever sets in suddenly with a rigor
and a temperature of about 104° Fahr. the first evening. The
thirst in typhus fever is usually troublesome for the first few
days. Delirium does not come on as a rule till towards the
end of the first week. The muscular power is greatly
depressed sometimes, even during the first stage of the dis-
order, the pi'ostration is extreme, and the tendency to stupor
and indifference to surrounding objects very great. Towards
the end of the first week the eruption peculiar to typhus
fever commonly begins to show itself, though sometimes it
does not appear until later. Sir William Jenner calls the
eruption which is distinctive of typhus fever, " the mulberry
rash," After the third day of the eruption no fresh spots
appear. It disappears in the course of the third week of the
disease. The character of this rash varies with its age. It
is never papular, but consists at first of very slightly elevated
spots, of a dull crimson colour. Each spot is flattened on its
surface, iiTegular in outline, and disappears completely under
the pressure of one's finger. In two or three days these spots
undergo a marked change. They are no longer elevated, they
become darker, dingier, more defined, and then they only fade
204 LECTURES ON NURSING. [Lect. XI.
and do not disappear under pressure. From this condition the
spots in most instances grow paler, pass into faintly marked
reddish-brown stains, and finally vanish. The spots or stains
composing this mulberry rash are generally very numerous,
set closely together, and sometimes they almost cover the
skin. They are usually spread over the trunk and extremities,
occasionally over the trunk only, and now and then they are
seen on the face. Each spot remains visible until the whole
rash disappears. To this rule there is one exception. The
eruption sometimes shows itself first on the backs of the
hands, and leaves those parts within twenty-four hours.
When numerous the spots have not all the same depth of
colour, consequently the surface has a mottled look. It is in
the course of the second week of the disease that death is
most apt to take place in typhus fever.
Typhus fever, after the first week, has a characteristic
odour of its own, by which nurses learn to knoAv it. Dr.
Murchison suggests that the vapour which imparts this
gmell, imparts with it the typhus poison, and he tells us also
that the pupils of the eyes are usually contracted in typhus.
During the third week of typhus fever, the patient's chance
of recovery improves. When convalescence has once fairly
begun it goes on rapidly, and recovery from typhus fever is
mostly both early and complete.
This disease is much less fatal to young children than it
is to adults ; after fifty-five years of age it is said to destroy
one-half of those whom it attacks.
Now, with regard to small-pox, or variola. Dr. Smart
tells us that there is no contagion so strong and sure, or that
operates at so great a distance, passing from house to house
and from street to street. The patient charges the air, and
everything about him, with a most subtle and deadly virus,
derived chiefly from the skin, and mucous membranes, but
not restricted to them.
Lect. XI.] LECTUBES ON NURSING. 20o
As you all know, the only protection against this terrible
disease is vaccination, which should be repeated at least once
after the fourteenth year.
Dr. Richai'dson observes that " people of the present day,
who complain of the temporary inconvenience and almost
infinitesimal danger of vaccination, can only do so thi-ough
ignorance of the hon-ible suffering, disgusting deformity, and
appalling mortality which attended small-pox in former
times. It is estimated that in England during the eighteenth
century, nearly one- third of all the inhabitants, ladies included,
were pitted Avith small-pox, which caused about ten per cent,
of all the deaths taking place every year. The mortality was
so great, that one out of every four, and, in some epidemics,
one out of every three, attacked, died of this fi-ightful malady;
and when we remember that every one seized with it became
immediately an object of danger, dread, and loathing to his
best friends and nearest relations, and, if he or she recovered,
was generally i*endered repulsive-looking for life, we can
faintly realize what a blessing Jenner's discovery has been to
the world."
Small-pox usually sets in with shai-p, feverish symptoms,
rigors, followed by heat and dryness of skin, with nausea,
vomiting, and pain in the back. Childi-en do not shiver, you
know, so in their case it is sometimes ushered in with an
attack of convulsions, which is the equivalent to a rigor in an
adult. The peculiar eruption almost always begins to show
itself on the third day of the fever. At first the pimples feel
hai"d like small shot under the skin. The eai'lier it comes,
the more severe the attack is likely to be. The eruption
comes out first on the face, then on the neck and wrists and
on the trunk, and lastly on the lower extremities. As a rule,
it does not cease to come out until the fifth day. " The
severity of the disease is almost always in direct proportion
to the quantity of the eruption. The number of pustules
206 LECTURES ON NURSING. [Lect. XI.
indicates, in the first place, the quantity of the variolous
poison which has been reproduced in the blood. In the
second place, it is also a direct measure of the extent to which
the skin suffers inflammation. Sometimes there are not more
than half a dozen pustules ; sometimes there are thousands.
If all these were collected into one, it would be an enormous
abscess. For both these reasons the system suffers commo-
tion, distress, and peril in proportion to the quantity of the
eruption." When the pustules are very many they run
together, and then it is called " confluent small-pox." The
pimples gradually increase in magnitude, but it is not till the
third day of their appearance that they begin to contain a
little fluid on their summits. It is the eighth day of the
disease, and the fifth day of the eruption, before they become
perfectly turgid. During the time in which they are thus
filling up, the face swells ; often to so great a degree that the
eyelids are closed and the skin between the pustules on the face
assumes a damask red colour. About the eighth day of the
eruption a dark spot makes its appearance on the top of each
turgid pustule, and at that spot the cuticle breaks, a portion
of the matter oozes out, and the pustule dries into a scab.
This process begins on the face, and pursues the same course,
only two or three days later, upon the extremities. The feet
and hands swell just as the face swelled, but they begin to
swell just as the features begin to resume their normal
size.
Many things are recommended to relieve the intolerable
itching and to prevent the pitting which is so frightfully dis-
figuring. Painting the surface with collodion, castor oil,
nitrate of silver, carbolic oil, glycerine, vaseline, and so on ;
but of course you will always use the application ordered, and
nothing has as yet been discovered to be infallible for this
purpose. There is least risk of fatal termination between the
ages of ten and fifteen ; below fire the complaint is often fatal,
Lect. XL] LECTURES ON NURSING. 207
and after forty the danger increases in proportion to the age
of the patient.
Chicken-pox is a very trifling complaint, and seldom
requires much ti-eatment beyond a warm bath. It generally
begins with slight fever, and within twenty-four hours a
number of small reddish pimples appear, generally on the
back; the second day these become vesicular, and by the
fifth day they have generally disappeared.
Measles begin with all the symptoms of a common cold,
running at the eyes and nose, sneezing, hoarseness, cough, and
difficulty of breathing ; the characteristic eruption usually
appears on the fourth day. It is two or three days in coming
out, beginning on the face, neck, and arms, then reaching the
trunk, and finally the lower extremities. " In this course it
resembles the eruption of small-pox. It fades ia the same
order, standing out for three days at least upon the face,
before it begins to decline ; so that its whole duration com-
prises a space of six or seven days. It becomes browner as it
fades. You may feel that the eruption is slightly elevated
above the general surface of the skin, especially upon the face,
which is somewhat bloated and swollen. The parts which
the rash has recently occupied are left covered with a dry,
small scurf, which crumbles away in a fine, branny powder.
You may remember that, unlike small-pox, measles are not
severe nor dangerous because the eruption is plentiful
and early. The einiption is the distinguishing feature of
measles, but the catarrhal affection is in every way the
most important. Diarrhoea is very apt to set in when
the rash is fading, but the great danger of measles is
pneumonia, which is very likely to supervene. The period of
incubation for measles is from ten days to a fortnight. The
contagion is active enough, but certainly it is less strong and
diffusive than that of small-pox.
You should use soft pieces of old rag or linen, instead of
208 LECTtRES ON i^URSlNa. [Lect. XI.
good pocket-handkerchiefs, to wipe the eyes, mouth, and nose
of patients saffei-ing from measles, as these discharges are
highly infectious, and it is best, when possible, to burn
material that has been in contact with them.
Scarlet fever is generally marked by the characteristic
affection of the throat and the distinctive rash. It is highly
contagious, and much more to be dreaded than measles.
The period of incubation for scarlet fever is short, usually
not exceeding five or six days, sometimes briefer still. The
i*ash of scarlet fever commences in minute points, which
speedily become so numerous and crowded, that the surface
appeal's to be universally red. " They begin on the neck, face,
and breast, and extend to the extremities, pervading at last
every part of the skin. It is peculiarly distinct at the bends
of the joints and on the chest and abdomen. The eruption
usually stands out for three or four days and then begins to
fade, disappearing altogether, as a rule, towards the end of
the seventh day." About this time desquamation of the
cuticle begins to take place — in small scurf or scales from
the face and body, in large flakes frequently from the
extremities.
The best way to prevent infection from these particles
which peel off is to anoint the patient all over with carbolic
oil, and this should be continued from the fourth day for six
weeks. If the patient is not able to bear carbolic oil, or the
doctor does not approve, he may possibly allow olive oil or
simple dressing to be rubbed over the patient's skin. Any
process which is likely to prevent the infected skin flying
about in a fine powder is very important, and, of course, if
the cuticle can be disinfected before it comes away from the
patient, so much the safer and better for all in contact with
him. The patient cannot be considered safe to mix with
others until the peeling is quite over. The severity of this
disease is chiefly marked by the extent of the throat mischief ;
Lect. XI.] LECTURES ON NURSING. 209
the tonsils may be simply inflamed, or they may become the
seat of extensive ulceration and even gangrene. You can
hardly attach too much importance to the necessity of guard-
ing your patient from all risk of cold during the convalescent
stage, for the slightness of the attack of fever is no guarantee
against the susceptibility to many diseases which scarlet
fever leaves. Inflammation of the kidneys, Bright's disease,
dropsy, are among the serious diseases to be feared as the
consequence of any carelessness in this respect.
After the process of desquamation is entirely over. Dr.
Richardson recommends that the patient should still be kept
isolated for a week, and should have a daily bath containing
carbolic acid solution, so that at last every square inch of the
body will have been thoroughly disinfected. Be very careful,
too, about the head and the hair, for the disease poison, both
of scarlet fever and of small-pox, is apt to linger among the
dandriff that accumulates at the roots of the hair.
Diphtheria, whooping-cough, mumps, ai'e all highly in-
fectious, but I think there is nothing special I need tell you
about them in addition to what I have already said.
Now, in conclusion, there are two extremes that nurses
must avoid with regard to infection as it concerns themselves
— the cowardly dread of it on the one hand, and the careless
disregard of it on the other. Perhaps you will think it
strange that it is the latter extreme that I am most afraid of
for you; but I am sure that is the one which is the more
likely to prove a temptation, unless you are carefully on your
guard against it. Women who fear infection for themselves
are greatly to be pitied; but they have no business to be
nurses, and the sooner they understand that they have mis-
taken their vocation the better it will be for themselves and
all concerned. Many unselfish people may fail as nurses
from lack of other essential qualities, but you may be sure
that no woman lacking that qualification has any fitness for
p
210 LECTUKES ON NURSING, [Lect. XL
the work at all. Except perhaps a natural shrinking that
may come across the bravest of you as the possibility of your
catching some horrible disease suggests itself to you, there
are not many nurses who find the idea a difficulty to them ;
neither must you suppose that I regard it as a selfish thing
to have the sensation of fear. It is not wrong or anything
but natural to have such a feeling occasionally ; the wrong
would only be in allowing one's self to yield to it.
If our wards were filled with an epidemic of cholera or
plague to-morrow, instead of our regular cases, I have not
the slightest doubt that nearly all of you would be as eager
to nurse them as though it were not fraught with great
danger to yourselves. But when it comes to the other extreme
of taking infinite pains and trouble to guard against the
infection that you have ceased to fear in the slightest degree
yourself, and with which you are so familiar that you have,
to all intents and purposes, ceased to realize its existence,
then many of you are not so conscientious in putting into
practice the knowledge you possess ; indeed, it is not too
much to say that many experienced nurses are culpably
negligent in this way. We are all apt to forget or to ignore
what we do not see or feel, and to take but little definite
notice of our everyday surroundings, and so perhaps there is
nothing so very remarkable in the fact that this generally
accepted attribute of human nature should be painfully
illustrated by nurses who devote their time solely to the care
of these cases. If only infection were a visible instead of an
invisible danger, and if only it could be borne in mind that it
is as real as though it could be felt and seen and touched,
what a comfort and help it would be !
What I want to impress upon you is that nurses know
the importance of taking these precautions which have
been enjoined upon them. Pi^obably they have done their
best conscientiously to carry them out to the letter, until
Lect. XI.] LECTURES ON NURSING. 211
familiarity has made them careless and indifferent. Now,
do you honestly think that any nurse has a right to
excuse herself, or to expect others to excuse her, for the
neglect of a single detail, when she hnoivs the consequences
viay be so terrible to others ? And, after all, the carelessness
of which I speak seldom arises from anything bat sheer
laziness — or, I fear I shonld add, a want of trtistivorthiness.
Perhaps you may not do any harm. That is true. But,
then, how can you, who know Avhat you are doing, run the
risk ? The mischief done may never be traced home to yon,
but does that alter the case ? Let me implore you again to
be very faithful over the little things ; or, if you cannot make
up your mind to all the trouble that entails, give up nursing
the sick, and find employment that does not bring the health
and happiness, and perhaps the lives, of your fellow-creatures
into your hands. I speak and feel forcibly on this matter.
It is no exaggeration to say that it is one which involves
questions of life and death to others, and of the cam-ying out
of high principles as opposed to lax and slovenly work from
yourselves.
The great encouragement in nursing fever cases is that so
ra.uch depends upon the nursing, as far as the result of the
disease is concerned. All nurses have a weakness for patients
who "do them credit," and it is the feeling that you are
fighting a stern battle, the issue of which depends largely
upon your care and skill, that so animates nurses with hope,
and rewards them for the anxiety of their work.
There is always the possibility — it is not more than that,
for the proportion of nurses who " catch " things from their
patients is very small in the aggregate — but there is the
possibility which no nurse need shut her eyes to, that she
may have to suffer herself, or that she may meet her death
as a direct consequence of attending to her patient. I have
already spoken to you of the quiet courage that nurses need
212 LECTURES ON NURSING. [Lect. XI.
to possess, and the possibility of danger to herself makes no
true woman turn from a clear call of duty. It is only natural
that I should anxiously hope that none of you will be called
upon to suffer in this way ; but if it does happen that the
angel of death thus greets any one of you, you will never
regret that he found you at your post, using your nurse's
talent faithfully to the end. The highest things that are
worth living for are worth dying for too, if the need arises ;
and if you are in earnest you will not be afraid that any
good to others will cost yourselves too dear. " Let love be
your motive and reward while you live." That is the
truest and the most encouraging thought that I can ask you
to take for your guidance in this, and indeed in every branch
of your work.
Lect. xii.j lectures on nursing. 213
LECTURE XII.
To-night I propose to say a few words to you in reference to
the ventilation, temperature, and light of your wards or
sick-rooms. I have not left it until the last because I con-
sider it of minor importance, but because there were other
details more likely to be of interest to probationers on their
first entrance into hospital life.
Dr. Anderson, in his adraii'able little book on "Medical
Nursing," says — "Air may be regarded as invisible, with-
out colour, taste, or smell. ... It is not a simple body ; it
is not one of the elements, as the ancients supposed, but a
compound body. It consists mainly of two elements, oxygen
and nitrogen. Oxygen is a gas, without colour, taste, oi*
smell ; it sustains animal life, and supports combustion, i.e.
it enables fuel to burn. It is the life-giving principle of the
air, although there is only one part of it to four of nitrogen.
Nitrogen is also devoid of colour, taste, or smell. It extin-
guishes life and light. It modifies the vital properties of the
oxygen, or, as has been said, ' it dilutes the oxygen as water
does wine or spirits.' These two elements form almost the
whole bulk of the atmosphere ; but there is a third body,
which, although there is only a trace of it in the air as a
whole, is so poisonous in itself, and so readily increases in
circumstances that concern us very directly, that we must
give it our most careful attention. I mean, of course, carbonic
acid gas. This is a compound body devoid of colour, but with
a slight smell, and a rather sour taste. It extinguishes light,
214 I^ECTURES ON NURSING. [Lect. XII.
and if breathed undiluted, destroys life instantly. . . . We
cannot remain in a room without increasing the quantity of
this poisonous gas. With every expiration we give out at
once impure air — air so far unfit to be breathed again by our
own selves. Hence arises the necessity for ventilation. But
besides breathing out this poisonous gas, we continually
remove some of the life-giving oxygen; the carbonic acid
expired being formed by the combination of oxygen with the
carbon of our bodies."
It is noteworthy that whereas animals, ourselves included,
use up oxygen and give out carbonic acid, plants do exactly
the reverse — take in carbonic acid and give out oxygen. Thus
the atmosphere of the external world is kept clear. But there
is one point in connection with this fact that you must re-
member. During the night, i.e. in darkness, plants give out
carbonic acid, consequently you must never allow growing
flowers to remain in a sick-room during the night. There is
no possible objection to them during the day ; on the contrary,
they do positive good, and help to purify the atmosphei-e. But
of course your own common sense will tell you not to select
flowers with a very strong smell, unless they chance to be a
special favourite of your patient. Now, " proper ventilation,"
says Dr. Parke, " is clean air displacing foul air constantly
and steadily, without chilling the patient." Miss Nightingale
writes still more emphatically on the subject, and declai-es
that " the very first rule of nursing, the first and the last
thing upon which a nurse's attention must be fixed, the first
essential to the patient, without which all the rest you can do
for him is as nothing, with which I had almost said you may
leave all the rest alone, is this — ' to keep the air he breathes as
pure as the external air without chilling him. ... To have the
air within as pure as the air without, it is not necessary, as
often appear to be thought, to have it as cold.^ " *
* Miss Florence Nightingale's " Notes on Nursing."
Lect. XII.] LECTURES ON NURSING. 215
You have, most of you, been here long enongh to notice
the attention paid to keeping the wards fresh and free from
smell, and can judge of the importance attached to this matter
by the trouble and expense incuiTcd in procuring various
ventilating appliances to facilitate the removal of impure air
and introduce as much fresh air as possible from outside-
Neglect of these px'ecautions in an institution of this sort
"would be followed by outbreaks of pycemia, erysipelas, and
other more or less preventable diseases.
Without in the least disparaging any scientific apparatus
which assists in maintaining a pure atmosphere in the wards,
it has been proved by experience that the most effectual
method of ventilating within the nurse's control, is opening
the windows a few inches from the top. Nothing entirely
supersedes this plan, and it is one which cannot be wholly
dispensed with. If you open the windows at the bottom you
will get a draught, probably coming directly on the patient,
and all the inmates oE the room, and run the risk of giving
them, rheumatism, stiff necks, and general discomfort, and
that, too, without fulfilling your object of thoroughly purify-
ing the air.
It is all very w^ell to throw up your windows at the
bottom when the external air is so mild and pleasant that you
can give your patients the benefit of it without risk of chilling
them, or of too far lowering the temperature of the room, but
it is of no use attempting to keep the atmosphere fresh by this
plan. To quote Miss Nightingale again — " The air thorough-
out a room is never changed by a draught in the lower part of
the room, but it is changed by an open window in the upper
part."
Ventilation, to be thorough, must be systematic, and is not
to be supplied in jerks now and again, just when you happen
to think of it. It is the frequent changes of temperature
which do harm, the sudden alternations between hot and cold
216 LliOTURES ON NURSINCi. [Lect. Xlt
whicli must be carefully guai'ded against and prevented, and
the fresh, eveji temperature that you must take so much pains
to maintain.
I have greatly to impress upon nurses that ventilation is
an important matter, to which they must give unremitting
attention, and any neglect of which will go far to counteract
the good effects of skilful nursing in other respects. A plan
for admitting fresh air into a room where cold draughts have
to be carefully guarded against was suggested by Mr. Hinckes
Bird, some time ago. The suggestion is, that a piece of wood
about three inches in depth, and made the exact width of the
window frame, should be inserted underneath the lower sash,
which should close down upon it. In this way the air must
enter by the space between the sashes, which, of necessity,
are open when the lower sash is raised. The plan is really
excellent. A still better and simpler way in new buildings is
to have the lower sill made three inches higJier than usual, so
that if the sash is lifted just less than that you have the same
effect as if the wood were there, no trouble of putting in or
taking out, and no draught.
It requires plenty of judgment and common sense to
ventilate judiciously. You have to fight against the proverbial
horror of fresh air peculiar to the class of people from which
most of your patients come, and which is frequently shared
in, to a large extent, by better educated people, who have not
studied the subject sufficiently to have overcome the popular
prejudice. I believe this prejudice is strengthened, or at any
rate is much slower in dying out, because nurses who have
grasped the notion that an abundant supply of fresh air ia
indispensable, frequently forget that cold and draught are dis-
comforts, and sometimes dangers to which their patients must
not be exposed.
If you allow your patients to be cold as a consequence of
bestowing fresh air upon them, it is not wonderful that they
Lect. XII.J lectures ON NURSING. 217
■will prefer being warm and so far comfortable to being thus
clumsily ventilated, and remember that in some cases by
chilling a patient you may cause fatal results.
Patients who are in bed can always be kept warm with
blankets and hot bottles, and yet allowed to have the air they
breathe as pui-e as though they were out of doors — at least
this is possible in well-built Avards and rooms, and it is always
the nurse's duty to do the best her circumstances will permit
to attain this object. You do not want to air your wards
from inside the building, but from outside. You must not
forget that " if windows are made to open, doors are made to
shut." If there is any necessity to have the door opened for
a time, shut the window for that time, and do not keep your
patients shivering in the draught because " it won't be for
long." That is no reason for making them take cold.
Close the windows near the patients when the doctor is
sounding them, when they are washing, or in any way
exposed ; but do not let the ward get close by forgetting to
open them afterwards. Be exceedingly careful not to have
wounds dressed Avith the draught from an open window
coming upon them, or you will run a great risk of causing
erysipelas. You will notice in accident and surgical wards,
that patients suffering from open wounds are generally placed
in beds away from the windows, not because they do not
require fresh air, but because in these cases all draughts have
to be so studiously avoided.
In medical wards it is becoming more and more the custom
to place patients suffering from chest complaints near open
windows, with the intention that the air they breathe shall be
fresh with as much oxygen as possible ; but it is at least
equally important that they should be shielded from the
sudden draught of cold air, which brings on a distressing
attack of coughing that could by a little thought have been
spared them.
218 LECTUEES ON NURSING. [Lect. XII.
The special prejudice against night air is so absurd that I
should scarcely have thought it necessary to speak of it, only
I know that you will again and again have an objection urged
against it by your patients, and it is best for you to have some
distinct ideas on the subject. " What air can people breathe
at night but night air ? " And surely the fresh night air from
outside must be more wholesome than the night air inside,
which has been inspired and sometimes re-inspired over and
over again. In large towns the night air is often the purest
to be had in the tAventy-four hours'; and it is said that the air
in London is never so good as after ten o'clock at night. Take
every convenient opportunity which presents itself to disabuse
your patients' minds of the erroneous views prevailing as to
" night air." I hope you will take as much care of yourselves
in this respect in your own bedrooms as you do of your
patients in the wards.
Until you have experienced it, you have no idea of the
difference it makes, if you have been sleeping in a room
where a fresh current of air has been circulating freely, or if
you have been sleeping in one where it has been carefully
excluded, and you have been breathing the same atmosphere
over and over again. " The expired air is deprived of fi-om
three to four parts of oxygen, is charged with this noxious
gas — carbonic acid — and also with morbid particles from the
lungs and blood ; and, until it is freely diluted in the sur-
rounding atmosphere, is deleterious to animal life. If confined
within a space, the air becomes overladen with carbonic acid
gas, and deprived of oxygen ; therefore, a correct balance
between the supply of oxygen and the demand can only be
maintained by admitting a supply of fresh air from the
outside." If you have opened your windows at the top and
insured this, you will find that it does not require half such
an effort to get up when you wake, which, I am sure, is an
important consideration to all nurses, and that the tendency
lect. xil] lectures on nursing. 219
to headache which every one feels after sleeping in a close
room, is to a great extent removed.
You will discover also that it is not only physically but
mentelly beneficial to avoid an impure atmosphere. When
people are cross and irritably inclined to quarrel with them-
selves and everybody Avith whom they come in contact, it
sounds somewhat ridiculous to suggest by way of a remedy
that the window should be opened; but, if you try the
experiment next time, you will probably find it effectual in
removing the fundamental cause of the mischief.
At any rate, when you are tired, listless, and disinclined to
exert yourselves, when you know no special reason why this
should be the case, it is quite worth while to discover how far
it is due to the air you have been breathing. So much is
within our own control in these little matters which affect our
health and comfort to so large an extent in everyday life, that
it is a great pity not to understand them, or to neglect to
carry them oat.
If you are not quite sure whether the atmosphere of your
room or ward is fresh, you can always settle the point by
leaving it and entering it again ; for you know that those
coming into a close place ai'e far more conscious of it than
those who, by remaining in it, have gradually become accus-
tomed to the atmosphere. It is a great mistake for a nurse
to suppose that letting out the fire will improve the ventila-
tion, for very much the contrary is the case. It will make a
room colder to let out the fire, but noi fresher — very far from
it, as the escape of warm air creates continuous circulation
of air in a x'oom. Many nurses are so far from understanding
this, that when,I have had occasion to remark that their wards
were close they have often said, " I will let the fire down," as
though that would be sure to improve it, whereas it would
simply make it worse. The broad rule for ventilating, with
commoa sense modifications to adapt it to circumstances, is —
220 LECTURES ON NURSING. [Lect. XII.
" make up the fire, open the windows at the top, and shut
the door." If the weather renders a fire inadmissible, of course
you will be careful to see that the chimney is open, and not
allow it to be closed up on any pretext whatever. A lamp
placed in the grate will ensure sufficient draught for purposes
of ventilation.
Now with regard to the warmth of the atmosphere in
which you are keeping your patients. It is scarcely less
important than their food. The temperature of medical wards
is generally considered best fi'om 60° to 64° or 65° Fahr. ;
surgical wards not above 60° Fahr., and sometimes a degree
or two below that. This is the rule to guide you when you
receive no special instructions on the point, but surgeons
differ on this as on other questions, and if you are told to do
anything different, you can only obey orders.
Many nurses apparently forget when the thermometer is
placed in the wards that it is meant for them to refer to, and
that it would be helpful to them if they cultivated a habit of
looking at it regularly. I should recommend all of you to
adopt this little plan for yourselves. You know what creatures
of habit we all are, and if you get into the way of watching
the variations of temperature now while you have com-
paratively very little to do with it, it will cease to be a trouble
to you, and you will not forget it when you are taking staff
nurse's duty and are responsible for the figure at which the
mercury of the thermometer stands in your wards.
Nurses should regularly look at the ward thermometer
whenever they come on and whenever they go off duty, for
their own satisfaction, besides referring to it if they ai'e in
any doubt as to the warmth of their ward. In addition to this,
night nurses should notice it towai'ds the dawn, when that
peculiar chill which precedes or comes with the very early
morning, and which must be already well known to many
of you, will certainly make the temperature fall below the
Lect. XII.] LECTURES ON NURSING. 221
required heat unless the nurse has wisely taken precautions
to make up her fire and guard against her patients feeling it.
The light of your wards is another matter which needs
a little attention. Except in those cases where light is painful
or prohibited — chiefly bmin or ophthalmic cases — the more
light and sunshine you can get into your wards, the better it
will be for all concerned. Of course you will not allow a
patient to lie with the sunshine streaming into his eyes, but
do not forget that the sun will not remain in that position all
day, and that if it has been necessaiy to draw down the
blind, you must draw it up. again afterwai'ds. Dark rooms
are never fresh, however much air may be passing through
them, and dark corners are not healthy. You may notice
that any dark or shady corner will retain a disagreeable smell
even if there is plenty of air in the immediate neighbourhood,
long after it has disappeared fi'om the rest of the room.
Sunshine is a necessity, physically as well as morally, and
it has a definite and powerful influence for good in many
ways. You must carefully regulate the artificial light also,
and remember that a gas-burner is said to consume as much
oxygen and gives out as much carbonic acid as four or five
men. Two candles or one good oil lamp are computed to
have the same effect upon the atmosphere as the presence
of one man.
Now, I think it may be a help to you if I endeavour to
recall briefly the chief points which I am anxious that you
, should keep in remembrance, as the result of your attendance
on this course of lectures.
You will all have realized that there is a wide distinction
between the work of a doctor and the work of a nurse ; that
there is a marked difference between the kind and degree of
knowledge necessary for each in their respective callings.
Doctors and nurses both aim at precisely the same object,
namely, the cure of the sick, or, at any rate, the alleviation
222 LECTURES ON NURSING. [Lect. XII.
of their suffering ; and this object can best be attained — or,
indeed, can only be attained — by each keeping to their own
line, with the sincere desire of aifording mutual help.
You will have understood, also, that nothing can be more
opposed to trained nursing than "amateur doctoring," so that
the slightest approach to this objectionable form of quackery
will, I trust, be impossible to all of you. Keep the clear idea
in your minds that nurses find their place as active agents in
carrying out a scientific system of treatment laid down by
the doctor, and if you reflect upon all that involves, it is not
possible to overrate the importance of your position, or to
mistake its limits.
I have explained to you that treatment usually presents
itself to us under one or more of the following aspects : —
First, to provide an antidote to any poison, and to remove
all sources of hai*m. Secondly, to put patients under the most
favourable condition for self-cure. Thirdly, to aid in treat-
ment by drugs which experience or experiment have shown
to be efficacious.
I told you that one form of treatment only might be
employed, or that a combination of all three might be con-
sidered desirable ; but you will find that all treatment can
be classed under one or more of these heads. Time will not
allow me to repeat illustrations of my meaning, but I hope
you will at least remember the fact.
Therapeutics — i.e. treatment — consists in the application
of natural agents, such as rest, cold, heat, and so on. We
have already spoken in detail of these things, for it is under
the second heading — i.e. that of " putting patients under the
most favourable condition for self-cure " — that most of your
work comes. We have seen that these remedial agents — as
well, of course, as innumerable others which have not as yet
been told you — can be applied either generally to the whole
body, or locally to any part for which they may be prescribed.
Lect. XII.] LECTURES ON NURSING. 223
Yoa will try and remember the points I have mentioned in
connection ^Yith ordinary and special bed-making, \vith the
•washing of helpless patients, and other matters involved in
a nurse's duties when her patient has to be kept absolutely
at " rest." We have said some little, too, on the padding of
splints and of other appliances for providing " local rest."
You will, I hope, be able to efficiently administer any of the
general or local applications of cold, which I so minutely
described to you; and, at any rate, I trust I said enough
to convince you of the positively harmful effect of allowing
an ice-bag to remain on when it has become a bag of warm
water. If you recognize the importance of such details, I
am confident that we shall not meet with any such evidences
of careless nursing in our wards. The administration of such
forms of dry or moist heat as may be ordered generally or
locally is, of coarse, not less important. You will not fail
to be accurate and careful in reference to the temperature
at which these remedies are applied by you; and you will
not forget that dry heat can be tolerated at a much higher
temperature than moist. It is not possible nor necessary
to repeat the items we have previously dwelt upon, but
please keep the manner in which these remedial agents act
clearly in your mind.
Cold and heat act, then, by modifying the supply of blood
to the surface — by diminishing it, which is the effect produced
by cold ; by increasing it, which is the effect produced by
heat. In addition to this alteration in the quantity of blood,
there is an alteration of sensibility — i.e. diminished sensibiHty,
as by cold, up to complete loss of sensation ; increased sensi-
bility, as by heat, up to scalding, with all the varied degrees
of sensibility between these two extremes, such as the sen-
sitiveness of the surface after poultices or fomentations, or
the coolness of a part after the continual application of an
evaporating lotion.
224 LECTURES ON NUESING. [Lect. XII.
The main uses of these natural agents, then, are: (1) to
modify amount of blood to surface ; (2) to reduce tempei-a-
ture ; (3) to increase temperature.
They act as cold-producers, by dii-ect abstraction of heat
from the surface, by conduction, and by evaporation. Yoa
know that if you put any cold substance close to a hot sub-
stance, the hot one will give up heat to the cooler body ; that
is what we mean by losing heat by conduction. Evaporation,
is the passage of a fluid into a gaseous state, and during the
process of evaporation heat is used up, and a fall of tem-
perature is produced. Again, these natural agents act as
heat-producers by the direct application of a hot substance,
or indirectly by diminishing evaporation and thus preventing
the fall of temperature.
I merely touch upon these points now with a view of
recalling the fuller explanation of them that I have previously
endeavoured to give you, and in the hope of leaving a clear
impression of these subjects on your mind.
I need say nothing to recall such details as I have men-
tioned in connection with your work in preparing for,
attending to, and niirsing opei^ation and accident cases.
These subjects will now be brought before you in a more
interesting form, and the repetition of them will serve to
remind you of any small points I have put before you. The
same applies to the remarks I have made in reference to
medical nursing. But in the mean time go on actively
cultivating your powers of observation, for this is a matter
you must attend to for yourselves. Observe on the system
I pointed out to you the other night, enlist all your senses
in the service of your patients, and cultivate, from a nursing
point of view, your faculties of hearing, seeing, smelling, and
touching. A certain amount of experience is essential before
these senses can be fully trained ; but I have no hesitation
in saying that this is far more a matter of education than of
lkot. xii.] .lectures on nursing. 225
time. You may be in a hospital twenty years, and leave it
absolutely ignorant of the meaning of systematical observation
of your patients, and rest under the delusion that you know
your work, because from long habit you cannot fail to notice
the existence of some striking symptom ! Whereas, in a very
short time you may so have acquired the hahit of methodical
observation, that in evei'y case you come across you will only
have to turn your attention to the symptoms of that individual
patient, and then none of them will escape you for want of
your powers of perception having been trained. It is of no
use taking up a book full of wisdom if you cannot read the
language in which it is written. It is of no use watching the
sick if you have not learnt, or are not learning, the signs
that are written in the plainest language for those that have
" eyes to see."
I am very appreciative of the kind attention you have
paid throughout these lectures to all that I have had to
say to you. If they serve to show that I am not ignorant
of, nor unsympathetic with, your difficulties, and to convince
you of the cordial interest I have in all that affects you and
your work, our time will not have been wasted.
In conclusion, will you let me urge upon you, as I did
three months ago, to keep steadily before you a very high
standard of the work you have chosen ? I want you to
i*ealize how much, how very much, the " tone " of the whole
nursing staff depends upon each individual member of it ; and
then you can decide, individually and collectively, if you mean
to rest contented with attaining anything short of the very
best. Think of the enormous power you exercise over each
other by yoiu- daily example. The influence of those in
authority is simply nothing in comparison with it. "We all
. feel the effect of public opinion more or less, and the majority
of people, if not all, are most influenced by that section of the
public, be it laxge or small, with which they are immediately
Q
226 LECTURES ON NURSING. [Lect. XII.
concerned. It is, so to speak, the mental atmosphere with
which we are surrounded, and as we were speaking just now
of the air we breathe, and the effect which its condition pro-
duces upon us, and the effect which every one produces upon
its condition, is it not a matter of vital importance to keep
this mental atmosphere pure and invigoi-ating ? Do you see
what a difference it makes, metaphorically speaking, whether
you are contributing your share of oxygen, or more than your
share of carbonic acid ? When Ave enter a room too heavily
laden with this noxious gas, we cannot trace the individual
share that each one has had in producing this condition of the
atmosphere ; we can only judge of the result. Thus it is with
what I am now speaking of as the mental atmosphere of this
little community. What will be the feeling of those who
enter it from outside ? Will their sensation on entering be,
" This place is stifling ; I wish I had never come in ? " or will
they be conscious of a strong under-current of earnestness
pervading the whole, and gradually driving out the denser
fumes of self-concentration, frivolity, and indifference, which
are apt to become so suffocating, and the influence of which is
likely to have such an insidious effect upon us before we are
aware of it ? If one of your number deteriorates instead of
improves, should it not be a question for each of you to ask
yourselves seriously if you have done your share in preventing
an occurrence which reflects sadly upon the whole ? Dismiss
wholly from your minds the notion that any one of you is too
insignificant for it to matter what you do or say. There is
nothing truer than the fact that while we live at all, it is
impossible to benefit or to injure ourselves only. The whole
human race is bound together in too close links of brother-
hood for that. In the words of a thoughtful writer, I would
ask you to " take the same pride in your life that a poet does
in making his poem, the painter his picture, the engineer his
bridge and his road. . . . Work on honestly, concentratedly.
Lect. XII.] LECTURES ON NURSING. 227
steadily at what is nearest yoiii- hand, and above youi- toil,
which may appear trivial enough, keep shining the fertilizing
warmth and brightness of ennobling thoughts and hopes."
Nursing is work that should develop all that is best and
highest and most womanly in you ; and if you find this is not
so, be sure there is something wrong in the spirit with which
you are doing it. Remember that the profession which you
have taken up, from motives as varied, probably, as your
individual characters, was of old intrusted to the holiest
women, and they did not find themselves the woi'se for it. Why,
then, should you ? Our lives and our work are exactly what
we determine to make them. Recognize these obvious truths,
and make the most of the great opportunities for usefulness
which now surround you on every side. I dwell the more
emphatically upon the good you can do to each other, because
it is more likely to be ovei'looked than what you can do for
your patients. There is perhaps a tendency to forget that the
bravest workei-s are apt to grow weary at times, and to do
less than their best for lack of a little opportune encourage-
ment. 'No one could give this better or so well as a fellow-
worker who happens to be feeling stronger than they are at
the moment. Probably yoxi will never have an idea of the
service you by word or example have rendered to others ; but
you will find that there is a curious I'esponse in all human
nature to words and acts that have a tendency to raise us
above our ordinary level.
" Whene'er a noble deed is wrought,
Whene'er is spoken a noble thought,
Oar hearts in glad surprise
To higher levels rise.
" The tidal wave of deeper souls
Into our inmost being rolls,
And lifts us unawares
Out of all meaner cares.
q2
228 LECTURES ON NURSING. [Lkct. XII.
" Hononr to those whose words and deeds
Thus help us in our daily needs,
And by their overflow
Raise us from what is low ! " *
And there is but one essential to enable you all to do this,
and that is that your work should be earnest and true fi'om
its very foundation.
" Beautiful it is to see and understand that no worth
known or unknown can die even in this earth," says Carlyle ;
" for the working of the good and brave endures literally for
ever and cannot die." Nothing else lasts, whatever it may
seem to do, and it is beyond all things encouraging to you to
reflect that no single effort for good can by any possibility be
really wasted.
Strive to keep such rules as are given you, not only to the
letter but to the spirit, because it is right for you to do so,
not because you get into trouble if you do not. If you choose
by influence and example to make an intensely honourable
feeling the guiding spirit of this place, it is perfectly possible
for you to do so, and you only can do this for yourselves.
Discipline can and will be officially maintained, of course ; but
that is taking such a low ground for you, and is a very poor
sort of thing compared to the loyal service which is due from
you to the hospital whose credit you have at stake when you
have once worn its uniform.
There ai'e some amongst you who have come to this work
in the hope of finding strength to bear their own troubles by
seeking to soothe the sorrow of others. To them I can only
say. Persevere in the brave path you have chosen, and never
doubt that rest and fresh courage will be your reward. In
proportion as you are enabled to forget yourself you will be
strong. " There is only one lamp which we can carry in
our hand, and which will burn through the darkest night,
* " Santa Filomena," Longfellow's Poems.
Lect. XII.] LECTURES ON NURSING. 229
and mate the light of a home for us in a desert place — it is
sympathy with everything that breathes."
You will be very poor when your life is over if you are
contented with mere surface work, and prefer to shut your
eyes to the deeper meanings of things in which you are
constantly taking part. Numbers will come within your
influence in the public life that you have now entered upon.
Take care that every single one shall be the better for coming
in contact with you. Men, and women too, grow sceptical
of human goodness and purity and kindness and truth,
because they see so little that will stand the test of daily
life ; they find so much to despise, so little to admire, when
they look around. But they will never fail to reverence and
respect such women as are worthy to inspire these feelings.
Let them find that chance in you. They will thankfully
avail themselves of it, and you cannot render men a greater
service than by making yourselves ^^ for them to believe in.
There is not one of you that could bear the sight of a
fellow- creature starving if you had food to give. Surely
I need not remind you that " man does not live by bread
alone." I have told you before that it is especially a woman's,
and still more a nurse's, privilege to " comfort and help the
weak-hearted." Strive not to grow weary of your noble task.
There is no such word as fail to those who are faithful.
Besides —
*' Others will take patience, labour to their heart and hand
From thy hand and thy heart and thy brave cheer,
And God's grace fructify through thee to all."
Rest assured that those in authority are desirous of helping
you to the utmost of their power, and for myself I simply
have no words to tell you with what intense earnestness I
wish each one of you success.
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